Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?
Reports occasional sleeplessness and anxiety
Cannot distinguish between "what is real" and "not real"
Expresses uncertainty about whether to change jobs
Reports sadness and low mood
The Correct Answer is B
Choice A reason: Occasional sleeplessness and anxiety are common stress responses and do not necessarily indicate mental illness. These symptoms may reflect temporary issues rather than a diagnosable psychiatric condition, lacking specificity for severe mental illness compared to reality-testing deficits, making this choice incorrect.
Choice B reason: Inability to distinguish reality from non-reality is a hallmark of psychosis, a severe mental illness symptom seen in disorders like schizophrenia. This indicates impaired reality testing, a critical diagnostic criterion, making it the clearest indicator of mental illness among the options, thus the correct choice.
Choice C reason: Uncertainty about job changes reflects normal decision-making stress, not a mental illness. It lacks specificity for psychiatric conditions, as it is a common life concern. This choice does not indicate a significant mental health impairment compared to reality-testing issues, making it incorrect.
Choice D reason: Sadness and low mood may suggest depression, but they are less specific than psychotic symptoms like reality distortion. These feelings can occur in non-clinical contexts, making them less definitive for mental illness compared to inability to discern reality, rendering this choice incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Discussing patient history with staff during care planning is permissible under HIPAA for treatment purposes. It ensures coordinated care within the healthcare team, not violating privacy, as it is limited to professional need-to-know, making this choice incorrect.
Choice B reason: Documenting daily behavior is standard practice in medical records for treatment continuity and legal documentation. It is protected under confidentiality laws and does not breach privacy when restricted to authorized personnel, making this choice incorrect for a privacy violation.
Choice C reason: Releasing information to an employer without consent violates HIPAA, which mandates patient authorization for disclosures outside treatment, payment, or operations. This breaches confidentiality, compromising the patient’s right to privacy, making this the correct choice for a privacy violation.
Choice D reason: Asking family for pre-hospitalization information is appropriate if done with patient consent or legal justification, such as assessing history for treatment. Without evidence of unauthorized disclosure, this does not inherently breach privacy, making this choice incorrect.
Correct Answer is A
Explanation
Choice A reason: Arranging social services addresses the patient’s eviction, a social determinant of health impacting mental stability. This holistic approach supports recovery by ensuring housing stability, aligning with psychiatric nursing’s focus on comprehensive care, making this the correct choice.
Choice B reason: Contacting the landlord directly exceeds the nurse’s role and may violate privacy. It does not address the patient’s immediate housing needs or mental health, making it less appropriate than coordinating with social services for professional support.
Choice C reason: Questioning the medication reaction’s validity is inappropriate without evidence and distracts from addressing the eviction. It undermines trust and does not support discharge planning, making this choice irrelevant to the patient’s current needs.
Choice D reason: Delaying discharge without clinical justification risks unnecessary hospitalization. The eviction requires social support, not prolonged admission, as mental status improvement is not specified as a concern, making this choice incorrect.
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