Mental Health Nursing Questions and Answers 1 NCLEX Test 25 Questions

A 22-year-old patient with schizophrenia experiences auditory hallucinations that instruct self-harm, highlighting the need for immediate safety measures. The situation presents several interventions, including detailed inquiry into the hallucinations, administration of PRN antipsychotics, and one-to-one observation. Emphasis is placed on ensuring patient safety by closely monitoring the individual and preventing potential self-injury. Evaluating these options underlines the critical role of nursing judgment in high-risk psychiatric care.

The primary focus is ensuring the patient’s safety by employing one-to-one observation due to the high risk of self-harm from command hallucinations. Constant supervision is deemed critical as it promptly addresses the imminent danger that alternative interventions fail to mitigate. While options like medication administration and group therapy have their roles, they do not offer the continuous monitoring required for this acute situation.

A 35-year-old patient with bipolar disorder experiences a manic episode characterized by high agitation, rapid speech, and grandiose thinking. Providing a quiet environment and encouraging rest helps reduce stimulation and prevent physical exhaustion. Avoiding interventions that challenge grandiose beliefs or match high energy levels prevents exacerbation of the manic symptoms.

When initiating antidepressant therapy, patients may experience a surge in energy before any mood improvement occurs, heightening the risk of suicide in the early treatment stage. The full therapeutic effects of the medication typically require several weeks to become evident, leaving a critical window where increased energy can lead to impulsive actions. Thus, close and vigilant monitoring for worsening depression or suicidal ideation is essential during this period.

A patient with generalized anxiety disorder faces constant worry that disrupts daily life and causes significant distress. Among various possible interventions, the use of relaxation techniques and deep breathing exercises emerges as the effective choice to minimize physiological anxiety symptoms and restore control. Other methods, such as avoiding stress, increasing caffeine intake, or using alcohol, are identified as impractical and potentially harmful.

A patient with obsessive-compulsive disorder experiences compulsive handwashing due to a fear of contamination. The recommended treatment involves gradually extending the intervals between handwashings to reduce the associated anxiety using exposure and response prevention. Abruptly stopping the behavior or ignoring it does not effectively manage the disorder, while focusing solely on hygiene education fails to target the core compulsion. This progressive approach is recognized as a therapeutically sound method to mitigate the compulsive behavior over time.

A 40-year-old patient with PTSD, experiencing flashbacks and nightmares, highlights the need for a safe space to process traumatic memories. Establishing a non-judgmental and empathetic environment allows for open discussion of feelings and experiences, which is essential for recovery. Avoiding trauma discussions, relying on distraction, or enforcing merely positive thoughts fails to address the root issues and delays healing.

A nurse caring for a patient with borderline personality disorder integrates strict boundaries as the cornerstone of effective treatment, ensuring a consistent environment that alleviates fears of abandonment. A structured approach reduces the patient’s anxiety by offering predictability and fostering healthier relationships. Alternative strategies, like avoiding intimacy or complete isolation, can worsen emotional instability, while focusing solely on problem-solving techniques overlooks essential relational and emotional needs.

Anorexia nervosa is characterized by an intense fear of weight gain and distorted body image, which necessitates a carefully managed nutritional approach. A controlled and monitored eating plan, developed collaboratively with the patient, addresses nutritional deficiencies while taking into account the individual's anxieties about food and body weight. This method avoids the pitfalls of an immediate high-calorie diet or untimely exercise, ensuring a safer and more effective path to healthy weight gain.

A patient with a history of alcohol use disorder shows alarming signs such as tremors, anxiety, and profuse sweating, indicating a dangerous withdrawal state. The priority is to administer prescribed medication to manage withdrawal symptoms and prevent life-threatening complications like seizures. Alternatives such as group therapy, caffeine fluids, or complete bed rest are inappropriate at this critical moment.

Providing a non-stimulating environment alongside deep, slow breathing helps manage the acute symptoms of a panic attack. This approach controls hyperventilation and reduces the overwhelming fear associated with panic disorder. Engaging in complex tasks or increased physical activity tends to worsen symptoms, while stimulants can exacerbate anxiety. Fostering calm and guided breathing techniques effectively aids in alleviating the intensity of panic episodes.

In a patient showing signs of depression with hopelessness and disinterest in activities, the priority is assessing self-harm and suicide risk to ensure a safe care plan. Evaluating this risk is crucial because interventions like high-energy group activities, social isolation, or pressured major life decisions can worsen the condition. This focused risk assessment enables the development of tailored and effective treatment strategies.

A patient with schizophrenia experiences auditory hallucinations instructing harm and displays marked agitation. The immediate focus is to ensure the safety of the patient and others by providing a secure environment and close supervision. Although exploring the nature of the hallucinations and underlying stress factors is valuable, mitigating potential danger takes precedence.

A nurse caring for a patient with agoraphobia recognizes the patient’s intense fear of situations where escape is challenging. The strategy focuses on gradual exposure combined with cognitive behavioral techniques to help the patient progressively confront and manage fears in a controlled setting. This approach avoids the risks of immediate exposure, complete avoidance, or reliance on sedative medications, effectively targeting the root causes of the anxiety.

A patient with bipolar disorder in a hypomanic state shows increasing irritability and decreased sleep, which may signal a potential escalation of mania. Continuous monitoring and prompt communication with the healthcare team are vital to adjust treatment as needed. Interventions such as high-intensity exercise, major financial decisions, or increased caffeine intake are avoided because they could worsen the symptoms.

Patients in severe depressive episodes require constant supervision for signs of suicidal thoughts or behaviors to ensure immediate intervention. Continuous observation prevents potential escalation of self-harm risks when the patient’s decision-making is impaired. Interventions like competitive sports, sudden group therapy, or major life changes are too overwhelming and inappropriate at this critical juncture. Focused monitoring provides essential support and safety during a vulnerable state.

A nurse caring for a patient with a history of recurrent depressive episodes emphasizes education as a key intervention for relapse prevention. By focusing on recognizing early signs of depression and implementing stress management techniques, the strategy empowers the patient to act promptly in the face of potential triggers. This proactive approach is preferred over extreme measures like avoiding all stress or discontinuing medication, as it facilitates early intervention and effective coping mechanisms.

When a patient with PTSD struggles with sleep and nightmares, establishing a peaceful sleep setting with relaxation techniques is essential. Overstimulation from activities like late-night television or rigorous exercise is avoided to prevent further disruption of sleep patterns. The focus is on techniques such as deep breathing and guided imagery, complemented by a quiet, dark, and comfortable bedroom. These strategies help in reducing sleep disturbances and support overall recovery.

Educating patients about OCD provides a clear understanding of the disorder and equips them with practical methods to manage compulsive behaviors. Focusing on effective coping strategies such as cognitive behavioral therapy, exposure and response prevention, and stress management promotes self-empowerment. Emphasizing excessive cleanliness or invalidating concerns by labeling fears as irrational can reinforce harmful behaviors. A balanced approach that integrates knowledge and real-world techniques lays the foundation for long-term improvement.

A patient overwhelmed by unrelenting worry finds a path to calm by embracing cognitive behavioral techniques. By challenging negative thought patterns and practicing focused relaxation exercises, the patient learns effective strategies to manage everyday anxiety. This approach intentionally avoids harmful behaviors such as isolation, avoidance, and substance misuse, leading to enhanced resilience and balanced well-being.

A nurse caring for a bipolar patient in a depressive phase can best support recovery by fostering engagement in purposeful activities. Such activities build self-esteem and counter the deep feelings of hopelessness by providing clear goals and a sense of accomplishment. Drastic life changes, isolation, or discontinuing medication only risk worsening the patient’s state. Emphasizing structured, goal-oriented tasks nurtures resilience and promotes a healthier outlook.

A nurse caring for a patient with antisocial personality disorder finds that maintaining clear, consistent boundaries and expectations is the most effective communication strategy. This approach promotes respect and safety while preventing potential conflicts. Techniques such as confronting behaviors publicly, engaging in power struggles, or displaying excessive sympathy are avoided as they may lead to hostility or perceived weaknesses.

Patients with somatic symptom disorder experience distressing physical complaints without a clear medical cause, making supportive care crucial. Validating their feelings rather than dismissing their symptoms helps to build trust and address underlying psychological distress. A consistent, empathetic approach avoids neglecting important health issues and fosters a constructive therapeutic relationship.

A patient suffering from acute stress disorder after trauma exhibits intrusive thoughts, hypervigilance, and sleep disturbances, underscoring the need for stability. Establishing a safe and structured setting fosters a sense of security critical for healing. Immediate, detailed trauma processing may overwhelm, while avoiding or distracting from the trauma fails to address the underlying distress.

Providing targeted support and therapy to navigate trauma is essential for effective care of dissociative identity disorder. Emphasis is placed on creating a safe and empathetic therapeutic environment that validates the patient's complex experience. The approach prioritizes coping with the underlying trauma rather than suppressing or hastily integrating alternate identities.

A nurse treats a patient diagnosed with narcissistic personality disorder by upholding firm professional boundaries while ensuring respectful, consistent care. The approach avoids excessive praise that may reinforce grandiosity or direct challenges that could provoke defensiveness. Instead, it provides steady, dignified treatment that does not validate distorted self-perceptions, fostering a healthier therapeutic relationship.