NCLEX Mental Health and Psychiatric Nursing

Question 1

A patient with schizophrenia tells the nurse, 'The CIA has implanted a chip in my brain to monitor my thoughts.' How should the nurse respond therapeutically?

Accepted Answer

Acknowledge the patient's distress without reinforcing or arguing against the delusion

Answer

Therapeutic communication with delusional patients involves acknowledging the distress the delusion causes without reinforcing the false belief or arguing against it, as arguing typically escalates agitation.

Question 2

A patient is admitted with a diagnosis of major depressive disorder. Which nursing intervention has the highest priority?

Accepted Answer

Assess for suicidal ideation and means

Answer

Safety is the priority in psychiatric nursing. Major depression carries significant suicide risk, making assessment for suicidal ideation, plan, and means the first and highest-priority intervention.

Question 3

A patient taking lithium carbonate for bipolar disorder develops coarse tremors, vomiting, and confusion. The serum lithium level is 2.4 mEq/L. The nurse should:

Accepted Answer

Hold lithium, notify the provider, and prepare for supportive care as lithium toxicity is present

Answer

Therapeutic lithium range is 0.6–1.2 mEq/L (maintenance) or 0.8–1.2 mEq/L (acute mania). A level of 2.4 mEq/L is toxic. Coarse tremor, vomiting, and confusion indicate moderate-to-severe toxicity requiring immediate intervention.

Question 4

A patient on a psychiatric unit with bipolar disorder states, 'I am the president of the United States and I need a phone right now to call the Pentagon.' The nurse recognizes this as:

Accepted Answer

Grandiose delusion consistent with mania

Answer

A grandiose delusion is a fixed, false belief about having special powers, identity, or importance. Believing one is the president when not is a classic grandiose delusion seen in manic episodes.

Question 5

A nurse is conducting a suicide risk assessment using the SAD PERSONS mnemonic. Which factor should the nurse assess?

Accepted Answer

Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness

Answer

SAD PERSONS is a validated suicide risk assessment tool. Each letter represents a risk factor: Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Mental Health and Psychiatric Nursing