Anxiety
A patient with generalized anxiety disorder presents to the clinic with persistent worry, restlessness, and difficulty concentrating. The nurse recognizes these symptoms as characteristic of:
A. Normal stress response
B. Pathological anxiety
C. Panic disorder
D. Phobic disorder
Answer: B. Pathological anxiety
Rationale: Anxiety becomes a disorder when it disrupts daily living, social, or occupational functioning. Normal stress (A) is transient. Panic disorder (C) involves discrete panic attacks. Phobic disorder (D) is fear of specific objects/situations.
A nurse prepares to apply restraints to a patient who is severely agitated and threatening staff. Which action is most appropriate before restraint application?
A. Document the patient’s behavior and alternatives attempted
B. Obtain informed consent from the patient’s family
C. Place the patient in seclusion first
D. Apply restraints immediately, then notify provider
Answer: A. Document the patient’s behavior and alternatives attempted
Rationale: Joint Commission requires documentation that less restrictive measures were attempted and failed before applying restraints. Consent (B) is not required in emergencies. Seclusion (C) may or may not be appropriate. Applying restraints without assessment (D) violates standards.
A patient with major depressive disorder reports no longer enjoying previously pleasurable activities, difficulty sleeping, and poor concentration. The nurse identifies these symptoms as:
A. Negative symptoms
B. Anhedonia
C. Psychomotor agitation
D. Cyclothymia
Answer: B. Anhedonia
Rationale: Anhedonia = loss of pleasure or interest, a hallmark of depression. Negative symptoms (A) are associated with schizophrenia. Psychomotor agitation (C) = restlessness or pacing. Cyclothymia (D) = chronic mood swings, not major depression.
A nurse cares for a patient with schizophrenia who states, “The government has installed cameras in my home to spy on me.” Which response is most therapeutic?
A. “That can’t be true. No one is watching you.”
B. “Tell me more about why you feel this way.”
C. “I don’t see cameras, but I understand this is frightening for you.”
D. “Let’s focus on reality so you can feel safer.”
Answer: C. “I don’t see cameras, but I understand this is frightening for you.”
Rationale: The nurse should acknowledge the patient’s feelings without reinforcing the delusion. (A) dismisses feelings, (B) encourages delusional discussion, (D) challenges reality prematurely.
A patient with panic disorder suddenly develops shortness of breath, chest tightness, and states, “I feel like I’m dying.” What is the nurse’s priority action?
A. Stay with the patient and provide calm reassurance
B. Explain that panic attacks are not life-threatening
C. Encourage the patient to deep breathe and relax
D. Call a code and prepare for advanced cardiac life support
Answer: A. Stay with the patient and provide calm reassurance
Rationale: In acute panic, the nurse must stay present, reduce fear, and ensure safety. Education and breathing techniques (B, C) can be used once the patient is calmer. A code (D) is not indicated unless other evidence of cardiac arrest exists.
During an acute panic attack, a patient is pacing, trembling, and stating, “I feel like I’m going to die.” What is the nurse’s priority action?
A. Encourage the patient to verbalize feelings
B. Provide detailed teaching about relaxation strategies
C. Stay with the patient and reduce external stimuli
D. Administer prescribed long-acting anxiolytic medication
Answer: C. Stay with the patient and reduce external stimuli
Rationale: In severe anxiety/panic, safety and calming the environment are the priority. (A) is helpful later. (B) teaching is ineffective during acute panic. (D) Long-acting meds are not first-line in immediate panic attacks.
Which of the following patients meets criteria for BH restraint use?
A. A patient who repeatedly removes their IV line
B. A patient who is yelling loudly at staff but remains in control
C. A patient attempting to punch a peer during group therapy
D. A patient refusing oral medications
Answer: C. A patient attempting to punch a peer during group therapy
Rationale: Restraints are indicated only when patient poses imminent danger to self or others. Removing lines (A) or refusing meds (D) does not justify restraints. Verbal aggression (B) does not meet criteria.
A patient with bipolar I disorder presents with pressured speech, grandiosity, and decreased need for sleep. Which nursing intervention is most appropriate during this acute manic episode?
A. Encourage patient to participate in group activities
B. Allow patient to negotiate unit rules for autonomy
C. Provide a low-stimulation environment and structured schedule
D. Encourage patient to verbalize feelings in long sessions
Answer: C. Provide a low-stimulation environment and structured schedule
Rationale: During acute mania, limit stimuli and structure the environment to reduce agitation and risk of harm. Group activities (A) and negotiation (B) escalate stimulation. Lengthy sessions (D) are not tolerated.
A patient in the prodromal phase of schizophrenia is most likely to demonstrate which finding?
A. Flat affect and social isolation
B. Delusions of persecution
C. Disorganized speech and echolalia
D. Severe cognitive impairment and mutism
Answer: A. Flat affect and social isolation
Rationale: The prodromal phase involves social withdrawal, flat/blunted affect, poor role functioning, and subtle cognitive changes. Delusions (B) and disorganized speech (C) emerge in the active phase. Severe impairment (D) is seen in the residual phase.
A nurse prepares care for a patient with bipolar disorder in acute mania. Which intervention is most therapeutic?
A. Encourage the patient to attend stimulating group therapy
B. Provide a quiet environment with structured activities
C. Set strict limits on the patient’s freedom to reduce risk
D. Encourage long verbal expression of thoughts and feelings
Answer: B. Provide a quiet environment with structured activities
Rationale: Low-stimulation, structured settings help reduce manic agitation. Group activities (A) overstimulate, strict limits (C) may escalate agitation, and long verbal sessions (D) are not effective in mania.
The nurse develops a care plan for a patient with obsessive-compulsive disorder (OCD). Which nursing intervention is most therapeutic?
A. Strictly limit time spent on compulsions
B. Provide structured schedule and allow time for rituals
C. Encourage the patient to stop rituals immediately
D. Reassure the patient that rituals are harmless
Answer: B. Provide structured schedule and allow time for rituals
Rationale: Nurses should support gradual change by allowing rituals initially, then reducing them progressively. Strict limits (A, C) increase anxiety. Reassurance without redirection (D) is nontherapeutic.
A patient is placed in 4-point restraints due to violent behavior. Which nursing action is a priority?
A. Reassess patient every 2 hours and release as soon as possible
B. Monitor circulation, skin integrity, and safety every 15 minutes
C. Offer fluids and toileting every 8 hours
D. Apply restraints so the patient cannot move their extremities at all
Answer: B. Monitor circulation, skin integrity, and safety every 15 minutes
Rationale: Frequent, ongoing assessment (every 15 min) is required to prevent complications (skin breakdown, impaired circulation, injury). Reassessing every 2 hrs (A) is not often enough. Needs must be offered q2h, not q8h (C). Restraints must allow movement for safety (D).
Which finding best indicates therapeutic effectiveness of lithium in a patient with bipolar disorder?
A. Decreased hallucinations and delusions
B. Improved sleep, decreased flight of ideas, and stabilized mood
C. Decreased anxiety and increased energy
D. Weight gain and slowed psychomotor activity
Answer: B. Improved sleep, decreased flight of ideas, and stabilized mood
Rationale: Lithium is a mood stabilizer that decreases manic symptoms and stabilizes mood. Hallucinations (A) are psychotic symptoms. Anxiety reduction (C) may occur but is not the primary goal. Weight gain/slowed activity (D) suggest side effects or toxicity.
Which assessment finding represents a negative symptom of schizophrenia?
A. Auditory hallucinations
B. Neologisms
C. Anhedonia
D. Clang associations
Answer: C. Anhedonia
Rationale: Negative symptoms = absence of normal functions (e.g., anhedonia, flat affect, social withdrawal, apathy). Hallucinations (A), neologisms (B), and clang associations (D) are positive symptoms.
A patient placed in 4-point restraints for violent behavior requires ongoing monitoring. Which assessment is most important to perform every 15 minutes?
A. Pain level and IV site
B. Circulation, skin integrity, and respiratory status
C. Medication administration record
D. Intake and output
Answer: B. Circulation, skin integrity, and respiratory status
Rationale: Safety checks every 15 minutes are required by policy to prevent complications like impaired circulation, skin breakdown, or airway compromise. Pain (A) and I&O (D) are important but not as frequent. MAR review (C) is unrelated.
A patient with substance-induced anxiety is admitted with tachycardia, tremors, and diaphoresis after abruptly stopping alcohol use. Which intervention is most appropriate?
A. Begin relaxation exercises and guided imagery
B. Administer benzodiazepine as ordered
C. Place the patient in restraints to prevent injury
D. Provide reassurance that symptoms are temporary
Answer: B. Administer benzodiazepine as ordered
Rationale: Alcohol withdrawal can cause life-threatening anxiety and seizures. Benzodiazepines are first-line. Nonpharmacological approaches (A, D) are helpful but not sufficient. Restraints (C) should only be last resort.
A patient in restraints becomes increasingly agitated and develops tachypnea and cyanosis. What is the nurse’s priority intervention?
A. Document changes in patient’s behavior
B. Remove restraints immediately and assess airway and breathing
C. Increase sedation to calm the patient
D. Call the provider to request seclusion instead
Answer: B. Remove restraints immediately and assess airway and breathing
Rationale: Patient safety and oxygenation are the highest priorities. Documentation (A) is secondary. Sedation (C) may be used later but doesn’t treat hypoxia. Seclusion (D) does not address respiratory distress.
A nurse is preparing care for a patient with major depression and suicidal ideation. Which nursing diagnosis is the highest priority?
A. Hopelessness related to chronic illness
B. Ineffective coping related to situational stressors
C. Risk for suicide related to hopelessness
D. Social isolation related to withdrawal
Answer: C. Risk for suicide related to hopelessness
Rationale: Patient safety is priority. Suicide risk supersedes psychosocial needs (A, B, D). Hopelessness contributes to the diagnosis but risk for suicide is the urgent priority.
A patient receiving haloperidol develops muscle rigidity, hyperthermia, and autonomic instability. What is the nurse’s priority intervention?
A. Administer benztropine (Cogentin) as prescribed
B. Notify the provider and prepare to administer dantrolene
C. Encourage fluid intake to flush out the medication
D. Hold the next dose and observe the patient closely
Answer: B. Notify the provider and prepare to administer dantrolene
Rationale: This presentation = neuroleptic malignant syndrome (NMS), a life-threatening emergency. Treatment = immediate discontinuation of antipsychotic, cooling measures, and dantrolene or bromocriptine. Benztropine (A) is for extrapyramidal symptoms, not NMS.
A patient with schizophrenia tells the nurse, “The voices are telling me I am worthless and should die.” Which nursing action is priority?
A. Encourage the patient to ignore the voices
B. Ask the patient what the voices are saying
C. Ensure patient safety with close monitoring
D. Reassure the patient that the voices are not real
Answer: C. Ensure patient safety with close monitoring
Rationale: Command hallucinations increase risk for self-harm or violence. Safety (C) is the highest priority. Exploring content (B) is useful but comes after safety is ensured. Ignoring (A) or dismissing (D) may escalate distress.
Which nursing diagnosis has the highest priority for a patient experiencing a panic attack?
A. Ineffective coping related to situational stressors
B. Social isolation related to fear of embarrassment
C. Risk for self/other-directed violence related to anxiety
D. Powerlessness related to inability to control symptoms
Answer: C. Risk for self/other-directed violence related to anxiety
Rationale: Safety is always the top priority. Severe anxiety/panic can escalate to unsafe behavior. Other diagnoses (A, B, D) are important but not immediately life-threatening.
Which nursing intervention best aligns with evidence-based practice for preventing behavioral restraint use?
A. Assigning additional staff to restrain agitated patients safely
B. Using de-escalation techniques and reducing environmental stimuli
C. Offering PRN antipsychotic medications at the first sign of agitation
D. Using restraints early before escalation to violence
Answer: B. Using de-escalation techniques and reducing environmental stimuli
Rationale: Evidence-based strategies focus on restraint prevention through verbal de-escalation, therapeutic communication, and modifying the environment. Extra staff (A) is not preventative. PRN meds (C) may be appropriate, but not the first-line. Restraints (D) are last resort, never preventive.
A patient in the progressive stage of mania is started on valproic acid. Which lab finding requires immediate intervention?
A. Platelets 90,000/mm³
B. Sodium 133 mEq/L
C. Potassium 3.6 mEq/L
D. Hemoglobin 11.2 g/dL
Answer: A. Platelets 90,000/mm³
Rationale: Valproic acid carries risk of thrombocytopenia and hepatotoxicity. Platelets <100,000 are critical and increase bleeding risk. Mild hyponatremia (B) and borderline potassium (C) are not immediately life-threatening. Hemoglobin 11.2 (D) is low but not urgent.
The nurse develops a care plan for a patient with schizophrenia who demonstrates echolalia and social withdrawal. Which nursing outcome is most appropriate?
A. Patient will deny hallucinations within 48 hours
B. Patient will interact with one peer for 10 minutes by discharge
C. Patient will verbalize understanding that delusions are not real
D. Patient will no longer engage in echolalia within 72 hours
Answer: B. Patient will interact with one peer for 10 minutes by discharge
Rationale: Outcomes for psychosis should be realistic, measurable, and focused on improving social interaction and functioning. Denying hallucinations (A) and recognizing delusions (C) may not be realistic. Eliminating echolalia (D) is not an achievable short-term outcome.
Which nursing diagnosis is highest priority for a patient admitted with severe major depressive disorder who is refusing to eat, staying isolated, and expressing hopelessness?
A. Imbalanced nutrition: less than body requirements
B. Social isolation related to withdrawal
C. Risk for suicide related to hopelessness
D. Powerlessness related to inability to cope
Answer: C. Risk for suicide related to hopelessness
Rationale: While nutrition and isolation are concerns, suicide risk always takes priority in major depression with hopelessness. Patient safety must be addressed first.