A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty.
What is your best nursing response?
A. No one really knows the cause of schizophrenia. It is not your fault and is not due to
anything you did in the past. It is important to understand this, to support your daughter,
and to find support for yourselves.
B. Does anyone in your family have schizophrenia, as this disease is known to be
genetic?
C. You may feel bad now, but there are so many other bad things out there, such as
cancer and paralysis.
D. Let me share with you some websites to help you deal with your guilt. - ansA. No one
really knows the cause of schizophrenia. It is not your fault and is not due to anything
you did in the past. It is important to understand this, to support your daughter, and to
find support for yourselves.
Reason: Schizophrenia has a multifocal origin and its cause may include a genetic
component. Support is needed for both patients and caregivers.
A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits
sudden, excessive motor activity with repetitive sit-ups. What is this behavior called?
A. Delusional.
B. Hallucinogenic.
C. Paranoid.
D. Catatonic. - ansD. Catatonic.
Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or
excessive motor activity.
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. - ansC. Safety.
Reason: Safety is the major principle underlying psychiatric nursing.
A 22-year-old female was admitted to the mental health unit with major depression and
suicidal ideation. She has a history of cutting her wrists intermittently throughout the last
2 years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals.
On day 3, she eats 80% of her meals and is talking to others in group. The nurse should
consider that the patient is
A. Showing improvement.
B. Highly suicidal.
,C. Exhibiting mood swings.
D. In need of electroshock therapy. - ansA. Showing improvement.
Reason: The patient improvement is based on increased socialization and increased
appetite.
A 35-year-old male patient has been brought to your hospital unit after making a suicide
attempt at his workplace. Which of the following interventions can you legally
implement?
A. Call the patient's girlfriend and inform her of his admission and visiting hours.
B. Physically search the patient for weapons and harmful materials.
C. Call the patient's boss at work and report him as in need of extended medical leave.
D. Place the patient in four-point restraints and begin an IV for sedation. - ansB.
Physically search the patient for weapons and harmful materials.
Reason: A suicide attempt is a serious and self-destructive behavior that demands
searching for weapons and harmful materials to increase safety.
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. - ansD. Grieving.
Reason: Grieving may be characterized by weight loss, sleep disturbances, and
messages from beyond.
A hypomanic patient tells you that she has been 'picking up energy from my car engine
and car CD player' while driving and has received five speeding tickets in the past 6
months. What would be one effective intervention to avoid fast driving?
A. Make a contract not to drive more than 55 miles per hour and drive with the CD
played turned off.
B. Call the local police and alert them to the patient's car license plate number and the
make and model of her car.
C. Ask the patient to "hand over the keys" to you, and tell her that now she must use a
cab or other public transportation until your next session.
D. Share with the patient that she cannot drink and drive. - ansA. Make a contract not to
drive more than 55 miles per hour and drive with the CD played turned off.
Reason: Contracts can see a patient through period of hypomanic agitation.
, A patient has been admitted to your unit with a drug overdose, and you need to assess
for acidosis and hypoxemia. Which test should you perform?
A. Complete blood count (CBC).
B. Serum electrolytes.
C. Partial thromboplastin time (PTT).
D. Arterial blood gases (ABG). - ansD. Arterial blood gases (ABG).
Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].
A patient who is psychotic has a formed bowel movement on the floor of his room. How
should you clean up this excrement?
A. Use a thick diaper or pad.
B. Wear gloves and use some paper towels or toilet paper.
C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution.
D. Wear a gown, shoe covers, mask, and chemotherapy-impervious gloves, and wash
the area with an ammonia with bleach 1:1 solution. - ansC. Wear gloves, use toilet
paper, and wash the area with a 1:10 bleach solution.
Reason: Clean all body fluids with an appropriate disinfectant such as 1:10 bleach
solution, using universal precautions.
A physical indicator of possible abuse in a battered woman would be a fracture of the
distal bones, such as the skull, face, or extremities.
A. TRUE
B. FALSE - ansA. TRUE
Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal
bones, are indications of battering. Also assess for dislocated shoulders and old
fractures.
Adolescent suicide has increased over the past and is among the top five causes of
death in U.S. adolescents.
A. TRUE
B. FALSE - ansA. TRUE
Reason: Adolescent suicides have quadrupled since 1950 and are the third leading
cause of death in U.S. adolescents.
Alcohol tolerance develops as a result of the central nervous system's adaptive
mechanisms.
A. TRUE
B. FALSE - ansA. TRUE
Reason: The central nervous system adapts, so more alcohol is needed to obtain the
initial effects of alcohol ingestion, especially euphoria.
What is your best nursing response?
A. No one really knows the cause of schizophrenia. It is not your fault and is not due to
anything you did in the past. It is important to understand this, to support your daughter,
and to find support for yourselves.
B. Does anyone in your family have schizophrenia, as this disease is known to be
genetic?
C. You may feel bad now, but there are so many other bad things out there, such as
cancer and paralysis.
D. Let me share with you some websites to help you deal with your guilt. - ansA. No one
really knows the cause of schizophrenia. It is not your fault and is not due to anything
you did in the past. It is important to understand this, to support your daughter, and to
find support for yourselves.
Reason: Schizophrenia has a multifocal origin and its cause may include a genetic
component. Support is needed for both patients and caregivers.
A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits
sudden, excessive motor activity with repetitive sit-ups. What is this behavior called?
A. Delusional.
B. Hallucinogenic.
C. Paranoid.
D. Catatonic. - ansD. Catatonic.
Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or
excessive motor activity.
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. - ansC. Safety.
Reason: Safety is the major principle underlying psychiatric nursing.
A 22-year-old female was admitted to the mental health unit with major depression and
suicidal ideation. She has a history of cutting her wrists intermittently throughout the last
2 years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals.
On day 3, she eats 80% of her meals and is talking to others in group. The nurse should
consider that the patient is
A. Showing improvement.
B. Highly suicidal.
,C. Exhibiting mood swings.
D. In need of electroshock therapy. - ansA. Showing improvement.
Reason: The patient improvement is based on increased socialization and increased
appetite.
A 35-year-old male patient has been brought to your hospital unit after making a suicide
attempt at his workplace. Which of the following interventions can you legally
implement?
A. Call the patient's girlfriend and inform her of his admission and visiting hours.
B. Physically search the patient for weapons and harmful materials.
C. Call the patient's boss at work and report him as in need of extended medical leave.
D. Place the patient in four-point restraints and begin an IV for sedation. - ansB.
Physically search the patient for weapons and harmful materials.
Reason: A suicide attempt is a serious and self-destructive behavior that demands
searching for weapons and harmful materials to increase safety.
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. - ansD. Grieving.
Reason: Grieving may be characterized by weight loss, sleep disturbances, and
messages from beyond.
A hypomanic patient tells you that she has been 'picking up energy from my car engine
and car CD player' while driving and has received five speeding tickets in the past 6
months. What would be one effective intervention to avoid fast driving?
A. Make a contract not to drive more than 55 miles per hour and drive with the CD
played turned off.
B. Call the local police and alert them to the patient's car license plate number and the
make and model of her car.
C. Ask the patient to "hand over the keys" to you, and tell her that now she must use a
cab or other public transportation until your next session.
D. Share with the patient that she cannot drink and drive. - ansA. Make a contract not to
drive more than 55 miles per hour and drive with the CD played turned off.
Reason: Contracts can see a patient through period of hypomanic agitation.
, A patient has been admitted to your unit with a drug overdose, and you need to assess
for acidosis and hypoxemia. Which test should you perform?
A. Complete blood count (CBC).
B. Serum electrolytes.
C. Partial thromboplastin time (PTT).
D. Arterial blood gases (ABG). - ansD. Arterial blood gases (ABG).
Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].
A patient who is psychotic has a formed bowel movement on the floor of his room. How
should you clean up this excrement?
A. Use a thick diaper or pad.
B. Wear gloves and use some paper towels or toilet paper.
C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution.
D. Wear a gown, shoe covers, mask, and chemotherapy-impervious gloves, and wash
the area with an ammonia with bleach 1:1 solution. - ansC. Wear gloves, use toilet
paper, and wash the area with a 1:10 bleach solution.
Reason: Clean all body fluids with an appropriate disinfectant such as 1:10 bleach
solution, using universal precautions.
A physical indicator of possible abuse in a battered woman would be a fracture of the
distal bones, such as the skull, face, or extremities.
A. TRUE
B. FALSE - ansA. TRUE
Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal
bones, are indications of battering. Also assess for dislocated shoulders and old
fractures.
Adolescent suicide has increased over the past and is among the top five causes of
death in U.S. adolescents.
A. TRUE
B. FALSE - ansA. TRUE
Reason: Adolescent suicides have quadrupled since 1950 and are the third leading
cause of death in U.S. adolescents.
Alcohol tolerance develops as a result of the central nervous system's adaptive
mechanisms.
A. TRUE
B. FALSE - ansA. TRUE
Reason: The central nervous system adapts, so more alcohol is needed to obtain the
initial effects of alcohol ingestion, especially euphoria.
