Psychiatric and Mental Health Nursing Flashcards

The nurse is developing a care plan for a patient with major depressive disorder. Which nursing diagnosis has the highest priority?

Answer: Risk for suicide related to hopelessness

In psychiatric nursing, Maslow's hierarchy guides priority. Risk for suicide is a life-threatening priority that supersedes all other nursing diagnoses. Safety is always the first priority regardless of other identified problems in a patient with depression.

A patient with paranoid schizophrenia refuses to eat, stating 'the food is poisoned.' Which nursing intervention is most appropriate?

Answer: Offer sealed, commercially packaged food the patient can open themselves

Offering sealed, unopened commercially packaged food allows the patient with paranoid delusions to verify the food has not been tampered with, thereby improving safety and nutritional intake. This respects the patient's paranoid belief while meeting a physiological need.

The nurse is assessing a patient's affect. The patient discusses a recent death in the family with no change in facial expression or emotional tone. This is described as:

Answer: Flat affect

Flat affect describes the complete absence of emotional expression in voice and face, regardless of the subject matter. Blunted affect is reduced (not absent) emotional expression. Labile affect involves rapid, unpredictable emotional shifts. Both flat and blunted are negative symptoms of schizophrenia.

A patient with dementia is repeatedly asking where their deceased spouse is. What is the most therapeutic response?

Answer: Redirect the patient to a pleasant activity without confirming or dwelling on the death

In dementia care, repeatedly confirming the death causes repeated grief without memory consolidation. Therapeutic fibbing or gentle redirection to pleasant activities is preferred over repeated reality orientation that causes distress. Lying ('just shopping') may occasionally be used with careful judgment.

The nurse is preparing to apply physical restraints to an agitated patient. Which action is most important?

Answer: Explore all less restrictive alternatives before applying restraints

Restraints are a last resort and must be used only when all less restrictive alternatives have been tried and failed. A physician order is required (retroactively in emergencies). Restraints carry risks including injury, aspiration, and psychological harm.

A nurse is administering lithium to a patient with bipolar disorder. Which instruction about diet and hydration is most important?

Answer: Maintain consistent sodium intake and adequate hydration — avoid low-sodium diets

Lithium is reabsorbed in the renal tubules alongside sodium. Low sodium intake (dehydration, low-salt diet, excessive sweating) causes the kidneys to reabsorb more lithium, raising serum levels to toxic range. Consistent sodium and fluid intake maintains stable lithium levels.