RN Psychosocial Integrity 2 — Questions and Answers
Question 1: A patient with anorexia nervosa is admitted with a BMI of 14. Which nursing action takes priority?
- Encourage the patient to eat three large meals per day
- Monitor electrolytes and cardiac rhythm (Correct answer)
- Arrange family counseling
- Provide education about healthy body image
Correct answer: Monitor electrolytes and cardiac rhythm
Severe malnutrition in anorexia nervosa causes electrolyte imbalances (especially hypokalemia and hypophosphatemia) and refeeding syndrome risk, making cardiac monitoring the physiological priority.
Question 2: A nurse notices a colleague appears intoxicated at work and smells of alcohol. The most appropriate action is:
- Cover the colleague's patients for the shift
- Report observations to the charge nurse or supervisor immediately (Correct answer)
- Confront the colleague privately and ask them to go home
- Document the observation and report at the end of the shift
Correct answer: Report observations to the charge nurse or supervisor immediately
Patient safety is the priority; suspected impairment must be reported to a supervisor immediately to remove the impaired nurse from patient care.
Question 3: Which intervention is most appropriate for a patient experiencing alcohol withdrawal on day 2 of hospitalization?
- Encourage ambulation and socialization
- Administer scheduled benzodiazepines per protocol and monitor for seizures (Correct answer)
- Provide high-stimulation activities to distract the patient
- Restrict IV fluids to prevent fluid overload
Correct answer: Administer scheduled benzodiazepines per protocol and monitor for seizures
Benzodiazepines are the pharmacological standard for alcohol withdrawal to prevent progression to seizures and delirium tremens; close monitoring is essential during peak risk (24–72 hours).
Question 4: A nurse is caring for a patient with borderline personality disorder who says, 'You are the best nurse here — all the others are terrible.' The nurse recognizes this as:
- Transference
- Splitting (Correct answer)
- Projection
- Reaction formation
Correct answer: Splitting
Splitting is a defense mechanism characteristic of borderline personality disorder in which people are seen as all good or all bad, with no middle ground.
Question 5: A patient with post-traumatic stress disorder (PTSD) is startled by a loud noise and begins hyperventilating. The nurse's priority intervention is:
- Leave the patient alone to self-regulate
- Administer a PRN anxiolytic immediately
- Use a calm voice to ground the patient using sensory-based techniques (Correct answer)
- Restrain the patient for safety
Correct answer: Use a calm voice to ground the patient using sensory-based techniques
Grounding techniques (e.g., 5-4-3-2-1 sensory method) delivered calmly help anchor a patient experiencing a PTSD flashback or hyperarousal response to the present moment.
Question 6: A patient with bipolar disorder in a manic episode is intrusive, demanding, and has not slept in 3 days. The nurse's priority intervention is:
- Encourage group therapy participation
- Provide a structured, low-stimulation environment and ensure rest and safety (Correct answer)
- Allow the patient to make all care decisions to promote autonomy
- Encourage physical exercise to channel excess energy
Correct answer: Provide a structured, low-stimulation environment and ensure rest and safety
A low-stimulation environment reduces sensory triggers that escalate mania; ensuring safety and rest are the physiological and behavioral priorities during acute mania.
RN Psychosocial Integrity 2
A patient with anorexia nervosa is admitted with a BMI of 14.
Which nursing action takes priority?