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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Encouraging the patient to argue with auditory hallucinations can escalate distress and reinforce engagement with the voices, which is non-therapeutic in schizophrenia management. Evidence-based practice emphasizes reducing focus on hallucinations through coping strategies, not confrontation, making this choice incorrect.

Choice B reason: Teaching distraction techniques, like listening to music, is an evidence-based non-pharmacological intervention for managing auditory hallucinations. It helps shift attention away from the voices, reducing their intensity and promoting coping, aligning with psychiatric nursing principles, making this the correct choice.

Choice C reason: Administering an additional dose of antipsychotic medication without prescriber consultation violates nursing scope of practice and safety protocols. It risks toxicity and side effects, such as extrapyramidal symptoms, making this choice unsafe and incorrect for managing hallucinations.

Choice D reason: Advising the patient to ignore hallucinations is oversimplified and often ineffective, as it dismisses the distress caused by symptoms. This approach lacks therapeutic support and does not provide practical coping strategies, making it less appropriate than teaching distraction techniques.

A. Improved memory B. Fewer visual hallucinations C. Reduced anxiety D. Increased alertness

Correct Answer is C

Explanation

Choice A reason: GABA, an inhibitory neurotransmitter, reduces neuronal activity, not enhances cognitive functions like memory. Memory improvement is associated with cholinergic or glutamatergic systems, not GABA, making this choice incorrect for the expected effect of GABA potentiation.

Choice B reason: Fewer visual hallucinations are associated with antipsychotics affecting dopamine, not GABA. GABA’s inhibitory effects calm the brain but do not directly target psychotic symptoms like hallucinations, making this choice incorrect for the medication’s effect.

Choice C reason: GABA potentiation, as with benzodiazepines, enhances inhibitory effects, reducing neuronal excitability and calming the central nervous system. This directly alleviates anxiety, a primary therapeutic effect, aligning with GABA’s role in anxiety disorders, making this the correct choice.

Choice D reason: Increased alertness is contrary to GABA’s inhibitory effects, which promote sedation. Stimulants, not GABAergic drugs, enhance alertness, making this choice incorrect, as GABA potentiation leads to calming, not stimulating, effects on the brain.

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Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a patient diagnosed with schizophrenia who is experiencing auditory hallucinations. Which intervention best supports the patient in managing these symptoms?

Correct Answer is B

Explanation

The nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which effect would be expected?

Correct Answer is C

Explanation

In which phase of group therapy should the nurse plan to first address termination?

An adolescent hospitalized after a physical outburst tells the nurse, "I’m going to kill my father, but you can’t tell anyone." Select the nurse’s best response.

Which action by a nurse indicates a breach of a patient’s right to privacy?

When using cognitive behavioral theory with an anxious, withdrawn patient, interventions should focus on which of the following?

When considering the suggestions of Hildegard Peplau, which activity should the nurse regularly engage in that supports the theory of interpersonal relations?

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?

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