Mental Health Nursing Flashcards

A patient with schizophrenia tells the nurse, 'The CIA has implanted a chip in my brain to monitor my thoughts.' The nurse documents this as:

Answer: A persecutory delusion

A fixed false belief that an organization is monitoring or controlling the person is a classic persecutory delusion.

A patient who has been taking lithium for bipolar disorder presents with coarse hand tremors, polyuria, and confusion. The nurse suspects:

Answer: Lithium toxicity

Coarse tremors (not fine), polyuria, and confusion indicate lithium toxicity, which requires immediate intervention.

A nurse is using motivational interviewing with a patient who has alcohol use disorder. Which response best reflects this technique?

Answer: 'Tell me what concerns you have about your drinking.'

Motivational interviewing uses open-ended questions to explore the patient's own ambivalence and motivation for change.

A patient receiving haloperidol develops muscle rigidity, high fever, altered consciousness, and autonomic instability. The nurse recognizes this as:

Answer: Neuroleptic malignant syndrome (NMS)

NMS is a life-threatening reaction to antipsychotics characterized by hyperthermia, muscle rigidity, altered consciousness, and autonomic dysfunction.

A nurse is completing a suicide risk assessment. Which factor represents the highest risk?

Answer: Previous suicide attempt with a lethal method

A history of previous suicide attempts, especially with a lethal method, is the strongest predictor of future suicide completion.

Which nursing response is most therapeutic when a patient in crisis says, 'I have nothing to live for'?

Answer: 'I hear you — it sounds like you're in a lot of pain. Can you tell me more?'

Therapeutic communication involves acknowledging the patient's feelings and inviting them to share more without minimizing their experience.