TIA Mental Health Nursing 1 — Questions and Answers
Question 1: 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:
- An auditory hallucination
- A persecutory delusion (Correct answer)
- A somatic delusion
- Thought broadcasting
Correct answer: A persecutory delusion
A fixed false belief that an organization is monitoring or controlling the person is a classic persecutory delusion.
Question 2: A patient who has been taking lithium for bipolar disorder presents with coarse hand tremors, polyuria, and confusion. The nurse suspects:
- Subtherapeutic lithium levels
- Lithium toxicity (Correct answer)
- Lithium withdrawal syndrome
- Normal side effects at steady state
Correct answer: Lithium toxicity
Coarse tremors (not fine), polyuria, and confusion indicate lithium toxicity, which requires immediate intervention.
Question 3: A nurse is using motivational interviewing with a patient who has alcohol use disorder. Which response best reflects this technique?
- 'You really need to stop drinking before it kills you.'
- 'Tell me what concerns you have about your drinking.' (Correct answer)
- 'Have you considered AA — it works for most people.'
- 'Your family is very worried and you should listen to them.'
Correct 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.
Question 4: A patient receiving haloperidol develops muscle rigidity, high fever, altered consciousness, and autonomic instability. The nurse recognizes this as:
- Tardive dyskinesia
- Akathisia
- Neuroleptic malignant syndrome (NMS) (Correct answer)
- Extrapyramidal symptoms (EPS)
Correct answer: Neuroleptic malignant syndrome (NMS)
NMS is a life-threatening reaction to antipsychotics characterized by hyperthermia, muscle rigidity, altered consciousness, and autonomic dysfunction.
Question 5: A nurse is completing a suicide risk assessment. Which factor represents the highest risk?
- Passive ideation without a plan
- Previous suicide attempt with a lethal method (Correct answer)
- Report of occasional hopelessness
- Moderate depression with good social support
Correct 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.
Question 6: Which nursing response is most therapeutic when a patient in crisis says, 'I have nothing to live for'?
- 'Things will get better — you'll see.'
- 'Why do you feel that way?'
- 'I hear you — it sounds like you're in a lot of pain. Can you tell me more?' (Correct answer)
- 'You have so much to be grateful for.'
Correct 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.
TIA Mental Health Nursing 1
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: