Psychiatric and Mental Health Nursing Flashcards

A patient with bipolar disorder is in a manic episode. Which nursing intervention is the priority?

Answer: Provide a safe, low-stimulation environment and maintain nutrition/hydration

During mania, patients are hyperactive, distractible, and may not eat or sleep. Providing a low-stimulation environment reduces sensory input that worsens agitation. Maintaining safety, nutrition, and hydration are paramount. Overstimulating activities can escalate the manic state.

The nurse is preparing a patient with depression for discharge. Which statement by the patient requires further intervention?

Answer: 'I finally feel better and found my old gun at home to clean it.'

Patients with depression are at highest risk for suicide when they first begin to feel better, as they regain energy while still harboring suicidal ideation. The combination of apparent improvement plus access to a firearm is a major red flag requiring immediate intervention.

A patient is brought to the ED agitated and confused, with dilated pupils, tachycardia, and dry skin. The nurse suspects:

Answer: Anticholinergic toxidrome

The anticholinergic toxidrome (from antihistamines, antipsychotics, tricyclic antidepressants) causes dry skin/mucous membranes, mydriasis (dilated pupils), tachycardia, confusion, urinary retention, and fever. Remembered as 'hot as a hare, dry as a bone, blind as a bat, red as a beet, mad as a hatter.'

The nurse is using the CAGE questionnaire to assess alcohol use. What do the letters stand for?

Answer: Cut down, Annoyed, Guilty, Eye-opener

CAGE stands for: Have you ever felt you should Cut down? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you ever had an Eye-opener (drink first thing in the morning)? Two or more 'yes' answers suggest a significant alcohol problem.

A patient with schizophrenia tells the nurse that the television is sending special messages only to them. This symptom is an example of:

Answer: Idea of reference

An idea of reference is a delusional belief that external events (TV, radio, strangers' conversations) have special personal relevance or messages directed specifically at the patient. It is a positive symptom of schizophrenia.

A nurse is conducting group therapy for patients with substance use disorders. Which therapeutic approach is the foundation of motivational interviewing (MI)?

Answer: Expressing empathy and supporting self-efficacy without judgment

Motivational interviewing uses a collaborative, person-centered approach based on expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. It avoids confrontation and instead evokes the patient's own motivation for change.