Psychiatric Mental Health Nursing NCLEX | Questions and Answers(A+ Solution guide)

A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his words make no sense to me. I don't understand what he wants me to do.' What is an appropriate nursing diagnosis? A. Ineffective denial. B. Bipolar mood disorder. C. Hyper-religiosity. D. Grieving. - D. Grieving. Reason: Grieving may be characterized by weight loss, sleep disturbances, and messages from beyond. Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptoms of A. Depression. B. Schizophrenia. C. Suicidal ideation. D. Bipolar manic episodes. - A. Depression. Reason: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary symptoms of major depression. Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30 minutes before his discharge, his roommate comes to you and says, 'He is talking crazy.' When you ask your patient how he is feeling, he states, 'I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.' Which type of mania-related symptoms is this patient exhibiting? A. Social. B. Cognitive. C. Behavioral.D. Perceptual. - B. Cognitive. Reason: Cognitive symptoms include inflated self-esteem and grandiosity. You need to assess whether a patient who has a mood disorder is ready for discharge. Which statement would indicate readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always make my mother help me or tell her to do so. She better help me. C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything. - C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. Reason: Verbalization of a plan for help and demonstration of care are realistic discharge criteria. An angry patient is in the community room. She picks up a chair and uses it to hit another patient on the head. When you come into the community room, what should your first response to the patient holding the chair be? A. Are you crazy? Hitting people can hurt them! B. Hitting others is unacceptable. Please put the chair completely down on the floor. C. How would you like it if I hit you over the head with a chair? D. You're in big trouble now. It's probably prison you are looking at! - B. Hitting others is unacceptable. Please put the chair completely down on the floor. Reason: Use words to indicate your lack of acceptance of the patient's behavior in a nonthreatening voice or tone. A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority? A. Socialization. B. Contracting for eating behavior.C. Safety. D. Administering the Beck depression scale. - C. Safety. Reason: Safety is the major principle underlying psychiatric nursing. Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-way street in his underwear and a T-shirt, shouting, 'I am being held against my will. I have personal rights.' Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions will add to everyone's safety in the acute care environment? A. Have hectic surroundings. B. Have consistent unit routines. C. Minimize staff interventions. D. Medicate the patient only if he has private health insurance. - B. Have consistent unit routines.