A patient experiencing a panic attack is hyperventilating, trembling, and says "I am going to die." Which nursing intervention is most appropriate?

Stay with the patient and use short, simple directions in a calm voice

Leave the patient alone in a quiet room until the symptoms subside

Explain in detail the physiology of the fight-or-flight response

Encourage the patient to explore childhood causes of the anxiety now

A 28-year-old male with schizophrenia has been taking haloperidol 10 mg daily for two weeks. He presents to the clinic with a temperature of 40°C (104°F), severe muscle rigidity, altered consciousness, and autonomic instability. Which action should the nurse take first?

Activate emergency medical services and discontinue haloperidol.

Administer benztropine as prescribed to reduce muscle rigidity.

Encourage increased fluid intake to prevent dehydration from hyperthermia.

Reassure the patient that these are common side effects that will subside.

A nurse is caring for a patient with schizophrenia who appears to be listening and responding to internal stimuli. The patient is smiling and nodding. What is the nurse's best initial action?

Ask the patient, 'What are you hearing right now?'

Tell the patient that the voices are not real and should be ignored.

Redirect the patient to a structured group activity.

Ignore the behavior to avoid reinforcing the hallucinations.

A nurse is caring for a patient diagnosed with schizophrenia who is pacing and muttering. The patient suddenly stops and says, "The voices are telling me to do bad things." Which action should the nurse take first?

Ask the patient what the voices are saying and if they plan to follow the commands.

Reassure the patient that the voices are not real and will go away with treatment.

Ask the patient to describe the voices' tone, gender, and other characteristics.

Administer the prescribed PRN antipsychotic medication immediately.

A 45-year-old patient with major depressive disorder has been on a selective serotonin reuptake inhibitor for 2 weeks. The patient, who was previously withdrawn and lethargic, now appears calm and is giving away personal belongings to other patients. Which action should the nurse take first?

Ask the patient directly about any thoughts of self-harm or suicide.

Notify the patient's family that the patient is showing signs of recovery.

Document the behavior as a sign of improved mood and increased socialization.

Encourage the patient to participate in group activities to build social connections.

A 28-year-old male with a known diagnosis of schizophrenia is admitted to the psychiatric unit. During the initial assessment, the nurse observes that the patient appears to be responding to internal stimuli, occasionally tilting his head and mumbling to himself. He states, "The voices keep telling me I am in danger." The patient also demonstrates a restricted range of emotional expression, has not initiated any activities since admission, and has been observed avoiding interactions with others. Which of the following findings is a positive symptom of schizophrenia?

Lack of initiative in activities

Restricted range of emotional expression

Avoidance of social interactions

A 42-year-old patient with bipolar disorder has been taking lithium carbonate 600 mg three times daily for six months. The patient reports persistent nausea, vomiting, and diarrhea for the past two days, along with a new coarse tremor in the hands. The patient appears ataxic when walking to the bathroom. Which action should the nurse take first?

Hold the lithium and notify the healthcare provider immediately.

Administer the scheduled dose of lithium with a small amount of food.

Encourage increased oral fluid intake and reassess in one hour.

Administer the prescribed antiemetic and document the symptoms.

A 32-year-old patient with schizophrenia has been stable on clozapine for 6 months. The nurse reviews the most recent complete blood count results: white blood cell count 2,500/mm³ and absolute neutrophil count 1,200/mm³. Which action should the nurse take first?

Administer the scheduled dose and increase ANC monitoring to at least weekly.

Hold the clozapine and schedule a repeat complete blood count in one week.

Administer the scheduled dose and repeat the complete blood count in 24 hours.

Hold the clozapine and notify the healthcare provider immediately.

← Adult Nursing

Mental/psychiatric nursing

18 original SNLE questions on mental/psychiatric nursing, each with an explanation for all four options. Part of Adult Nursing, worth 40% of the Saudi Nursing Licensure Examination.

Q01 / 10medium0 correct

Adult Nursingmediumq013

A patient tells the nurse, "I have been thinking that everyone would be better off without me. I have my father's pistol at home." What is the nurse's most appropriate response?

All 18 questions

Every question below, with the reasoning for all four options. Try to answer before you open one.

Mental/psychiatric nursing · medium
A patient tells the nurse, "I have been thinking that everyone would be better off without me. I have my father's pistol at home." What is the nurse's most appropriate response?
- A"Let's talk about something more positive to take your mind off this."
- B"I will keep this between us so you feel safe talking to me."
- C"Are you thinking about killing yourself, and do you have a plan?"
- D"You have so much to live for — think about how your family would feel."
Show the answer and why the others fail
Answer: C. "Are you thinking about killing yourself, and do you have a plan?"
A
Changing the subject is avoidance; it invalidates the patient and forfeits critical assessment information.
B
Confidentiality cannot be promised when there is risk of serious harm; the nurse has a duty to involve the treatment team.
C — correct
Direct, explicit questioning about suicidal intent and plan is the evidence-based approach. It does not increase risk, and it is required to assess lethality — access to a firearm makes this a high-risk situation demanding immediate safety measures.
D
Reassurance and guilt-inducing appeals shut down disclosure and do not address immediate lethality.
TakeawayAsk about suicide directly and specifically — asking does not plant the idea, and plan plus means access defines the level of risk.
Mental/psychiatric nursing · easy
A patient experiencing a panic attack is hyperventilating, trembling, and says "I am going to die." Which nursing intervention is most appropriate?
- AStay with the patient and use short, simple directions in a calm voice
- BLeave the patient alone in a quiet room until the symptoms subside
- CExplain in detail the physiology of the fight-or-flight response
- DEncourage the patient to explore childhood causes of the anxiety now
Show the answer and why the others fail
Answer: A. Stay with the patient and use short, simple directions in a calm voice
A — correct
During panic, attention and information processing are severely narrowed. A calm presence with brief, concrete directions provides external structure and helps the patient regain control.
B
Abandonment during panic intensifies terror; the patient needs a calm presence.
C
Complex teaching cannot be processed during panic-level anxiety; education is done after the episode resolves.
D
Insight-oriented exploration during acute panic increases distress; it belongs in later therapeutic work.
TakeawayIn panic-level anxiety, stay with the patient and give short simple directions — teaching and insight work come only after the acute episode.
Mental/psychiatric nursing · medium
A 28-year-old patient with schizophrenia has been taking haloperidol for 3 weeks. The patient develops a temperature of 39.8°C, severe muscle rigidity, confusion, and labile blood pressure. The nurse suspects which condition?
- AMalignant hyperthermia
- BSerotonin syndrome
- CExtrapyramidal side effects
- DNeuroleptic malignant syndrome
Show the answer and why the others fail
Answer: D. Neuroleptic malignant syndrome
A
Malignant hyperthermia is a rare reaction to volatile anesthetics and succinylcholine, not antipsychotics. It presents with hyperthermia, muscle rigidity, and rhabdomyolysis, but the history of haloperidol use makes NMS more likely.
B
Serotonin syndrome typically presents with hyperthermia, neuromuscular excitation (clonus, hyperreflexia), and autonomic instability, but it is associated with serotonergic medications (e.g., SSRIs, MAOIs), not haloperidol, a dopamine antagonist.
C
Extrapyramidal side effects (EPS) include dystonia, akathisia, parkinsonism, and tardive dyskinesia. While EPS can occur with haloperidol, they do not typically cause high fever, severe rigidity, or autonomic instability.
D — correct
Neuroleptic malignant syndrome (NMS) is a life-threatening reaction to antipsychotic medications like haloperidol. It is characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic instability (e.g., labile blood pressure, tachycardia).
TakeawayNeuroleptic malignant syndrome is a medical emergency characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic instability in patients taking antipsychotic medications.
Mental/psychiatric nursing · medium
A 28-year-old male with schizophrenia has been taking haloperidol 10 mg daily for two weeks. He presents to the clinic with a temperature of 40°C (104°F), severe muscle rigidity, altered consciousness, and autonomic instability. Which action should the nurse take first?
- AActivate emergency medical services and discontinue haloperidol.
- BAdminister benztropine as prescribed to reduce muscle rigidity.
- CEncourage increased fluid intake to prevent dehydration from hyperthermia.
- DReassure the patient that these are common side effects that will subside.
Show the answer and why the others fail
Answer: A. Activate emergency medical services and discontinue haloperidol.
A — correct
The patient is exhibiting signs of neuroleptic malignant syndrome (NMS), a medical emergency requiring ICU-level care. The first action is to activate EMS for immediate transfer to an emergency department and discontinue the offending agent to prevent further deterioration.
B
Benztropine is an anticholinergic used for acute dystonia or parkinsonism, not for neuroleptic malignant syndrome (NMS). It will not address the life-threatening hyperthermia and autonomic instability.
C
While hydration is important in NMS management, oral fluids are contraindicated in a patient with altered consciousness due to aspiration risk. The priority is emergency transfer and discontinuation of the drug.
D
These symptoms are not common benign side effects; they indicate a life-threatening condition. Reassurance delays critical treatment and could lead to fatal outcomes.
TakeawayNeuroleptic malignant syndrome (NMS) is a life-threatening reaction to antipsychotics characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic instability. Immediate actions include discontinuing the offending drug and activating emergency medical services for transfer to an ICU setting.
Mental/psychiatric nursing · medium
A nurse is caring for a patient with schizophrenia who appears to be listening and responding to internal stimuli. The patient is smiling and nodding. What is the nurse's best initial action?
- AAsk the patient, 'What are you hearing right now?'
- BTell the patient that the voices are not real and should be ignored.
- CRedirect the patient to a structured group activity.
- DIgnore the behavior to avoid reinforcing the hallucinations.
Show the answer and why the others fail
Answer: A. Ask the patient, 'What are you hearing right now?'
A — correct
This open-ended question assesses the content of the patient's auditory experience to identify any command hallucinations that may pose a safety risk, while avoiding validation of the hallucination as real.
B
Challenging the patient's perception can damage the therapeutic relationship and increase anxiety; it is not the initial priority.
C
Redirection may be appropriate later, but the initial priority is to assess the content of the hallucinations for safety.
D
Ignoring the behavior misses an opportunity to assess the patient's mental status and potential safety concerns.
TakeawayWhen a patient appears to be responding to internal stimuli, the nurse's priority is to assess the content of the hallucinations for command or safety risks, using neutral, non-validating language that does not reinforce the hallucination as real.
Mental/psychiatric nursing · medium
A nurse is caring for a patient diagnosed with schizophrenia who is pacing and muttering. The patient suddenly stops and says, "The voices are telling me to do bad things." Which action should the nurse take first?
- AReassure the patient that the voices are not real and will go away with treatment.
- BAsk the patient what the voices are saying and if they plan to follow the commands.
- CAsk the patient to describe the voices' tone, gender, and other characteristics.
- DAdminister the prescribed PRN antipsychotic medication immediately.
Show the answer and why the others fail
Answer: B. Ask the patient what the voices are saying and if they plan to follow the commands.
A
Providing false reassurance or challenging the patient's perception can increase anxiety and damage the therapeutic relationship. It also fails to assess the potential for harm, which is the immediate priority.
B — correct
When a patient reports command hallucinations, the nurse must first assess the content of the commands and the patient's intent to act on them. This directly evaluates the risk of harm to self or others and guides immediate safety interventions.
C
While assessing the characteristics of auditory hallucinations is part of a comprehensive evaluation, it does not address the immediate safety risk posed by command hallucinations. The priority is to determine if the patient intends to act on the commands.
D
Medication may be necessary, but the nurse must first assess the content of the commands and the patient's intent to act on them. Administering medication without this assessment could delay essential safety measures.
TakeawayWhen a patient reports command hallucinations, the nurse's first action is to assess the content of the commands and the patient's intent to follow them, as this determines the immediate risk of harm to self or others and guides safety interventions.
Mental/psychiatric nursing · medium
A 45-year-old patient with major depressive disorder has been on a selective serotonin reuptake inhibitor for 2 weeks. The patient, who was previously withdrawn and lethargic, now appears calm and is giving away personal belongings to other patients. Which action should the nurse take first?
- ANotify the patient's family that the patient is showing signs of recovery.
- BDocument the behavior as a sign of improved mood and increased socialization.
- CEncourage the patient to participate in group activities to build social connections.
- DAsk the patient directly about any thoughts of self-harm or suicide.
Show the answer and why the others fail
Answer: D. Ask the patient directly about any thoughts of self-harm or suicide.
A
Notifying the family of recovery is inappropriate because the patient's behavior may indicate increased suicide risk, not recovery. The nurse must first assess and ensure safety.
B
Giving away possessions is a warning sign for suicide, not simply improved mood. Documenting it as positive progress delays critical safety interventions.
C
While social engagement is beneficial, it is not the priority when a patient exhibits potential suicide warning signs. Safety assessment must come first.
D — correct
The patient's behavior (giving away belongings) is a classic warning sign for suicide. The nurse's priority is to assess suicide risk directly and ensure safety.
TakeawayGiving away personal belongings is a critical warning sign of suicidal intent, even when a patient appears calmer; immediate suicide risk assessment is the priority.
Mental/psychiatric nursing · medium
A 28-year-old male with a known diagnosis of schizophrenia is admitted to the psychiatric unit. During the initial assessment, the nurse observes that the patient appears to be responding to internal stimuli, occasionally tilting his head and mumbling to himself. He states, "The voices keep telling me I am in danger." The patient also demonstrates a restricted range of emotional expression, has not initiated any activities since admission, and has been observed avoiding interactions with others. Which of the following findings is a positive symptom of schizophrenia?
- ALack of initiative in activities
- BAuditory hallucinations
- CRestricted range of emotional expression
- DAvoidance of social interactions
Show the answer and why the others fail
Answer: B. Auditory hallucinations
A
Lack of initiative, or avolition, is a negative symptom characterized by decreased motivation to start or persist in goal-directed activities.
B — correct
Auditory hallucinations are a positive symptom, representing an excess or distortion of normal perception.
C
Restricted range of emotional expression, or blunted affect, is a negative symptom reflecting a diminution of normal emotional reactivity.
D
Avoidance of social interactions, or social withdrawal, is a negative symptom reflecting a loss of interest in interpersonal relationships.
TakeawayPositive symptoms of schizophrenia reflect an excess or distortion of normal functions (e.g., hallucinations, delusions), while negative symptoms reflect a diminution or loss of normal functions (e.g., blunted affect, avolition, social withdrawal).
Mental/psychiatric nursing · medium
A 42-year-old patient with bipolar disorder has been taking lithium carbonate 600 mg three times daily for six months. The patient reports persistent nausea, vomiting, and diarrhea for the past two days, along with a new coarse tremor in the hands. The patient appears ataxic when walking to the bathroom. Which action should the nurse take first?
- AAdminister the scheduled dose of lithium with a small amount of food.
- BEncourage increased oral fluid intake and reassess in one hour.
- CAdminister the prescribed antiemetic and document the symptoms.
- DHold the lithium and notify the healthcare provider immediately.
Show the answer and why the others fail
Answer: D. Hold the lithium and notify the healthcare provider immediately.
A
Administering more lithium would worsen toxicity. The symptoms indicate lithium toxicity, so the dose should be held, not given.
B
Oral fluids are unlikely to be tolerated due to persistent vomiting and are insufficient for moderate lithium toxicity, which requires IV fluid resuscitation. The priority is to hold lithium and notify the provider.
C
Treating nausea with an antiemetic does not address the underlying lithium toxicity and may delay essential treatment. The nurse must first hold the lithium and notify the healthcare provider.
D — correct
Nausea, vomiting, and diarrhea are early signs of lithium toxicity, while coarse tremor and ataxia indicate moderate toxicity. The priority is to stop further lithium intake and promptly inform the provider for a stat lithium level and further orders.
TakeawayGI symptoms (nausea, vomiting, diarrhea) are early signs of lithium toxicity, while coarse tremor and ataxia indicate moderate toxicity. The nurse's first action is to hold the lithium and notify the healthcare provider for a stat lithium level and further management.
Mental/psychiatric nursing · medium
A 32-year-old patient with schizophrenia has been stable on clozapine for 6 months. The nurse reviews the most recent complete blood count results: white blood cell count 2,500/mm³ and absolute neutrophil count 1,200/mm³. Which action should the nurse take first?
- AHold the clozapine and schedule a repeat complete blood count in one week.
- BAdminister the scheduled dose and increase ANC monitoring to at least weekly.
- CAdminister the scheduled dose and repeat the complete blood count in 24 hours.
- DHold the clozapine and notify the healthcare provider immediately.
Show the answer and why the others fail
Answer: B. Administer the scheduled dose and increase ANC monitoring to at least weekly.
A
Holding clozapine is unnecessary for mild neutropenia; the drug should be continued with weekly ANC monitoring, not held.
B — correct
For mild neutropenia (ANC 1,000–1,499/mm³), clozapine may be continued, but ANC must be monitored at least weekly until it returns to ≥1,500/mm³.
C
Repeating the CBC in 24 hours is not required for mild neutropenia; weekly monitoring is sufficient and the dose should not be held.
D
Holding clozapine is not indicated for mild neutropenia (ANC 1,000–1,499/mm³); the drug should be continued with increased monitoring.
TakeawayClozapine REMS classifies ANC 1,000–1,499/mm³ as mild neutropenia. The drug may be continued, but ANC must be monitored at least weekly until it recovers to ≥1,500/mm³. Interruption is required only for moderate (ANC 500–999) or severe (ANC <500) neutropenia.
Mental/psychiatric nursing · medium
A 45-year-old patient with schizophrenia has been taking haloperidol for two years. During a routine clinic visit, the nurse observes involuntary, repetitive lip smacking and tongue protrusion. The patient is unaware of these movements. Which action should the nurse take first?
- AAssess the movements using the AIMS and notify the healthcare provider.
- BAdminister the prescribed as-needed benztropine injection.
- CReassure the patient that these movements are temporary and will resolve.
- DHold the haloperidol immediately and monitor for withdrawal symptoms.
Show the answer and why the others fail
Answer: A. Assess the movements using the AIMS and notify the healthcare provider.
A — correct
The Abnormal Involuntary Movement Scale (AIMS) is the standard tool for early detection and monitoring of tardive dyskinesia. The nurse should assess and report findings so the provider can consider medication adjustments.
B
Benztropine is an anticholinergic used for acute dystonic reactions, not for tardive dyskinesia. It would not relieve these symptoms and may worsen them.
C
Tardive dyskinesia can be irreversible, especially if the offending medication is continued. Reassuring the patient without further assessment is inappropriate and may delay necessary intervention.
D
Abruptly discontinuing haloperidol can cause withdrawal or relapse of psychotic symptoms. The decision to stop or change medication must be made by the healthcare provider after assessment.
TakeawayTardive dyskinesia is a potentially irreversible movement disorder caused by long-term antipsychotic use; early detection using the AIMS and prompt reporting to the provider are essential to prevent progression.
Mental/psychiatric nursing · medium
A 28-year-old patient with major depressive disorder has been taking fluoxetine 40 mg daily for 6 months. Two days ago, the patient was prescribed tramadol for acute back pain. The patient now presents to the clinic with agitation, diaphoresis, hyperreflexia, and a temperature of 38.2°C (100.8°F). The nurse suspects serotonin syndrome. Which action should the nurse take first?
- AEncourage oral fluids and a quiet room.
- BApply cooling blankets for hyperthermia.
- CWithhold the fluoxetine and tramadol doses.
- DAdminister PRN lorazepam for agitation.
Show the answer and why the others fail
Answer: C. Withhold the fluoxetine and tramadol doses.
A
Hydration and a low-stimulation environment are supportive interventions, but they are insufficient to manage serotonin syndrome. The immediate priority is to discontinue the serotonergic drugs.
B
External cooling is an important supportive measure for hyperthermia, but it does not address the underlying cause. The first step must be to stop the offending medications to prevent worsening.
C — correct
Serotonin syndrome is a potentially life-threatening condition caused by excess serotonin. The nurse's immediate action is to prevent further serotonin accumulation by withholding the serotonergic agents, which is the most direct way to halt progression.
D
Benzodiazepines such as lorazepam are used to manage neuromuscular symptoms of serotonin syndrome, but they do not stop the ongoing accumulation of serotonin. The first priority is to discontinue the causative medications.
TakeawayIn serotonin syndrome, the nurse's first action is to withhold the causative serotonergic medications to prevent further accumulation. Supportive measures such as benzodiazepines, cooling, and hydration are secondary and follow discontinuation of the offending agents.
Mental/psychiatric nursing · medium
A 45-year-old patient with severe major depressive disorder is scheduled for electroconvulsive therapy (ECT) this morning. The patient has been on the unit for two days and has not responded to antidepressant medication. Which nursing action is most important before the procedure?
- AVerify that the patient has been NPO for at least 6 hours.
- BAsk the patient to void before transport to the treatment room.
- CAdminister the prescribed anticholinergic medication 30 minutes before the procedure.
- DRemove the patient's dentures and any jewelry.
Show the answer and why the others fail
Answer: A. Verify that the patient has been NPO for at least 6 hours.
A — correct
Ensuring the patient has had nothing by mouth for 6–8 hours is essential to minimize the risk of aspiration during anesthesia and the seizure. This is the highest priority pre-procedure nursing action.
B
Having the patient void promotes comfort and prevents incontinence during the seizure, but it is not as critical as verifying NPO status to prevent aspiration.
C
Anticholinergic agents may be given to reduce secretions and prevent bradycardia, but this is typically done by the anesthesiologist or as a specific pre-procedure order; the most critical safety check is NPO status to prevent aspiration.
D
Removing dentures and jewelry is a standard safety measure, but it is secondary to confirming NPO status, which directly prevents a life-threatening complication.
TakeawayBefore ECT, the nurse must verify that the patient has been NPO for 6–8 hours to reduce the risk of aspiration during anesthesia and the induced seizure.
Mental/psychiatric nursing · medium
A 22-year-old patient with major depressive disorder is being discharged after starting fluoxetine 20 mg daily. The nurse provides medication teaching. Which statement by the patient indicates a need for further teaching?
- A"I should start feeling less depressed within a few days."
- B"I should avoid drinking alcohol while taking this medication."
- C"I will let my doctor know if I start having thoughts of harming myself."
- D"I might experience some nausea or headache when I first start taking it."
Show the answer and why the others fail
Answer: A. "I should start feeling less depressed within a few days."
A — correct
This statement indicates a need for further teaching because therapeutic effects of fluoxetine typically take 2–4 weeks; early improvement in energy without mood improvement can increase suicide risk.
B
This statement reflects correct understanding because alcohol can worsen depression and increase side effects such as drowsiness and dizziness.
C
This statement reflects correct understanding; patients should be instructed to report any suicidal ideation, especially during the initial treatment period when risk may increase.
D
This statement is correct; gastrointestinal upset and headache are common early side effects of fluoxetine.
TakeawayAntidepressants like fluoxetine take 2–4 weeks to improve mood, but energy may return sooner, potentially increasing suicide risk; patients must be closely monitored and report any suicidal thoughts.
Mental/psychiatric nursing · medium
A 45-year-old male is admitted to the medical unit for alcohol detoxification. He has a 10-year history of heavy daily alcohol use. On the second day of hospitalization, the nurse notes that he is diaphoretic, has a heart rate of 110 bpm, and reports feeling 'shaky inside.' Which of the following actions should the nurse take first?
- AProvide a quiet, dimly lit environment to reduce stimulation.
- BScore the patient's withdrawal using the CIWA-Ar scale.
- CEncourage oral fluid intake to prevent dehydration.
- DAdminister the prescribed benzodiazepine for symptom control.
Show the answer and why the others fail
Answer: B. Score the patient's withdrawal using the CIWA-Ar scale.
A
A low-stimulation environment is supportive but not the priority before scoring withdrawal severity.
B — correct
The CIWA-Ar scale quantifies withdrawal severity, allowing safe, symptom-triggered benzodiazepine dosing.
C
Hydration is important but secondary to scoring withdrawal severity to guide treatment.
D
Benzodiazepine administration without a CIWA-Ar score may lead to over- or under-treatment; scoring should be done first.
TakeawayIn alcohol withdrawal, use the CIWA-Ar scale to objectively assess symptom severity and guide benzodiazepine administration.
Mental/psychiatric nursing · medium
A 48-year-old patient with a history of heavy alcohol use is admitted for detoxification. Twenty-four hours after the last drink, the patient is diaphoretic, has a heart rate of 110 bpm, blood pressure 150/95 mmHg, and is tremulous. Which action should the nurse take first?
- AAdminister thiamine as prescribed.
- BInitiate seizure precautions.
- CAdminister lorazepam as prescribed.
- DPlace the patient in a quiet, dimly lit room.
Show the answer and why the others fail
Answer: C. Administer lorazepam as prescribed.
A
Thiamine is given to prevent Wernicke's encephalopathy, but it does not treat the acute symptoms of alcohol withdrawal such as tachycardia, hypertension, and tremors. Addressing the immediate withdrawal symptoms is the priority.
B
Seizure precautions are a safety measure to protect the patient if a seizure occurs, but they do not treat the withdrawal syndrome or prevent seizure activity.
C — correct
Lorazepam is a benzodiazepine, the first-line medication for alcohol withdrawal. It reduces symptom severity and prevents progression to severe withdrawal, including seizures and delirium tremens.
D
A quiet environment helps reduce sensory stimulation and agitation, but it does not address the underlying pathophysiology of withdrawal or prevent life-threatening complications.
TakeawayBenzodiazepines are the first-line pharmacological treatment for alcohol withdrawal syndrome to reduce symptoms and prevent progression to severe withdrawal, including seizures and delirium tremens. Symptom-triggered dosing based on a validated scale (e.g., CIWA-Ar) is recommended. Thiamine is given to prevent Wernicke's encephalopathy but does not treat acute withdrawal. Environmental and safety measures are supportive, not the priority action.
Mental/psychiatric nursing · medium
A nurse on a psychiatric unit is caring for a patient with major depressive disorder who has been taking phenelzine for 2 weeks. The patient's lunch tray arrives, and before the patient begins eating, the nurse notes it contains aged cheddar cheese, pepperoni pizza, and a glass of red wine. Which action should the nurse take first?
- ANotify the healthcare provider of the error.
- BRemove the tray from the patient's room.
- CCheck the patient's blood pressure.
- DExplain the dietary restrictions to the patient.
Show the answer and why the others fail
Answer: B. Remove the tray from the patient's room.
A
Notifying the provider is necessary to correct the dietary order, but it is not the immediate priority. The nurse must first prevent the patient from consuming the contraindicated foods.
B — correct
The nurse's first action is to remove the tray to prevent the patient from eating tyramine-rich foods (aged cheese, pepperoni, red wine) that could trigger a hypertensive crisis. While removing the tray, the nurse should briefly explain the reason to maintain therapeutic rapport and reduce agitation.
C
Checking blood pressure is a routine assessment for patients on MAOIs, but it is not the first priority because the patient has not yet consumed the tyramine-rich foods, so there is no immediate risk of a hypertensive crisis. The nurse must first prevent ingestion.
D
Education about MAOI dietary restrictions is important but is not the first priority. The patient might begin eating while the nurse is explaining, so the tray must be removed first to ensure immediate safety.
TakeawayPatients taking MAOIs must avoid tyramine-rich foods (e.g., aged cheeses, cured meats, red wine) to prevent a hypertensive crisis. If such foods are present and the patient has not yet eaten, the nurse's first action is to remove the tray while briefly explaining the reason to maintain therapeutic rapport. Subsequent steps include assessing the patient, providing education, and notifying the provider.
Mental/psychiatric nursing · medium
A 22-year-old patient with schizophrenia started taking haloperidol 3 days ago. The nurse enters the room and finds the patient conscious but distressed, with eyes deviated upward, neck twisted to the right, and tongue protruding. Which action should the nurse take first?
- AAdminister the prescribed as-needed lorazepam intramuscularly.
- BAdminister the prescribed as-needed benztropine intramuscularly.
- CApply warm compresses to the neck and gently reposition the head.
- DNotify the healthcare provider of the assessment findings.
Show the answer and why the others fail
Answer: B. Administer the prescribed as-needed benztropine intramuscularly.
A
Lorazepam is a benzodiazepine that may be used as an adjunct or alternative for acute dystonia if anticholinergics are contraindicated, but it is not the first-line treatment. The priority is to administer an anticholinergic agent to rapidly reverse the dystonic reaction.
B — correct
The patient is exhibiting an acute dystonic reaction (oculogyric crisis, torticollis, tongue protrusion), a common extrapyramidal side effect of first-generation antipsychotics. The immediate treatment is an anticholinergic medication such as benztropine, which rapidly reverses the muscle spasms.
C
Warm compresses and repositioning are ineffective for acute dystonia, which results from an imbalance in dopaminergic and cholinergic activity in the basal ganglia. Pharmacological intervention with an anticholinergic agent is required.
D
Notifying the healthcare provider is important, but the nurse must first administer the prescribed anticholinergic to rapidly reverse the dystonic reaction. Delaying treatment could allow progression to laryngeal dystonia, compromising the airway and posing a safety risk.
TakeawayAcute dystonic reactions, such as oculogyric crisis and torticollis, are extrapyramidal symptoms that can occur within days of starting antipsychotic treatment. They require immediate administration of an anticholinergic agent (e.g., benztropine) to prevent potential airway compromise from laryngeal dystonia.

Mental/psychiatric nursing

All 18 questions

A patient tells the nurse, "I have been thinking that everyone would be better off without me. I have my father's pistol at home." What is the nurse's most appropriate response?

A patient experiencing a panic attack is hyperventilating, trembling, and says "I am going to die." Which nursing intervention is most appropriate?

A 28-year-old patient with schizophrenia has been taking haloperidol for 3 weeks. The patient develops a temperature of 39.8°C, severe muscle rigidity, confusion, and labile blood pressure. The nurse suspects which condition?

A 28-year-old male with schizophrenia has been taking haloperidol 10 mg daily for two weeks. He presents to the clinic with a temperature of 40°C (104°F), severe muscle rigidity, altered consciousness, and autonomic instability. Which action should the nurse take first?

A nurse is caring for a patient with schizophrenia who appears to be listening and responding to internal stimuli. The patient is smiling and nodding. What is the nurse's best initial action?

A nurse is caring for a patient diagnosed with schizophrenia who is pacing and muttering. The patient suddenly stops and says, "The voices are telling me to do bad things." Which action should the nurse take first?

A 45-year-old patient with major depressive disorder has been on a selective serotonin reuptake inhibitor for 2 weeks. The patient, who was previously withdrawn and lethargic, now appears calm and is giving away personal belongings to other patients. Which action should the nurse take first?

A 32-year-old patient with schizophrenia has been stable on clozapine for 6 months. The nurse reviews the most recent complete blood count results: white blood cell count 2,500/mm³ and absolute neutrophil count 1,200/mm³. Which action should the nurse take first?

A 45-year-old patient with schizophrenia has been taking haloperidol for two years. During a routine clinic visit, the nurse observes involuntary, repetitive lip smacking and tongue protrusion. The patient is unaware of these movements. Which action should the nurse take first?

A 45-year-old patient with severe major depressive disorder is scheduled for electroconvulsive therapy (ECT) this morning. The patient has been on the unit for two days and has not responded to antidepressant medication. Which nursing action is most important before the procedure?

A 22-year-old patient with major depressive disorder is being discharged after starting fluoxetine 20 mg daily. The nurse provides medication teaching. Which statement by the patient indicates a need for further teaching?

A 48-year-old patient with a history of heavy alcohol use is admitted for detoxification. Twenty-four hours after the last drink, the patient is diaphoretic, has a heart rate of 110 bpm, blood pressure 150/95 mmHg, and is tremulous. Which action should the nurse take first?

A 22-year-old patient with schizophrenia started taking haloperidol 3 days ago. The nurse enters the room and finds the patient conscious but distressed, with eyes deviated upward, neck twisted to the right, and tongue protruding. Which action should the nurse take first?