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 A

Explanation

Choice A reason: In Peplau’s orientation phase, the nurse establishes trust, fosters collaboration, and sets boundaries to build a therapeutic relationship. This foundation is critical for patients with psychiatric disorders, ensuring a safe space for engagement, making this the correct choice.

Choice B reason: Medication adherence is a clinical intervention addressed later, in the working phase, not orientation. The initial phase focuses on relationship-building, not specific treatments, making this choice incorrect for the orientation phase’s goals.

Choice C reason: Coping skill development occurs in the working phase, after trust is established. Orientation prioritizes relationship foundations like trust and boundaries, not skill-building, making this choice incorrect for the initial nurse-patient interaction phase.

Choice D reason: Long-term goals are addressed in the working or termination phases, not orientation, which focuses on establishing trust and rapport. Setting goals prematurely may hinder relationship-building, making this choice incorrect for the orientation phase.

A. How do you feel about having imbalanced neurotransmitters? B. Neurotransmitters are chemicals that help your brain communicate; an imbalance can affect mood and behavior C. Let’s focus on your medication to fix the imbalance D. Your doctor can explain that better than I can

Correct Answer is B

Explanation

Choice A reason: Asking about feelings explores emotions but does not address the patient’s question about neurotransmitters. Educational queries require informative responses to enhance understanding, not redirection to feelings, making this choice non-therapeutic and incorrect for the patient’s need.

Choice B reason: Explaining neurotransmitters as brain communication chemicals directly addresses the patient’s question. It provides clear, accurate information about their role in mood and behavior, aligning with patient education principles in psychiatric nursing, making this the correct, informative response.

Choice C reason: Focusing on medication avoids explaining neurotransmitters, failing to address the patient’s educational need. It shifts focus prematurely to treatment, which may confuse the patient, making this response less effective and incorrect for providing the requested information.

Choice D reason: Deferring to the doctor dismisses the nurse’s role in patient education, undermining trust. Nurses are equipped to explain basic concepts like neurotransmitters, and this response fails to meet the patient’s need for understanding, making it non-therapeutic and incorrect.

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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

Hildegard Peplau came up with the phases of the nurse-patient relationship. What does the nurse address during the orientation phase with a patient diagnosed with a psychiatric disorder?

Correct Answer is A

Explanation

A patient asks, "What are neurotransmitters? My doctor said mine are imbalanced." Select the nurse’s best response.

Correct Answer is B

Explanation

Which comment indicates the patient perceived the nurse was caring?

A nurse is caring for a patient with a mental health disorder. Which approach best supports therapeutic care?

Which tasks are safe and appropriate to be performed by a basic-level nurse for a patient suffering from mental illness?

A nurse is preparing morning medications for all patients, and one patient says, "I am not taking any of those pills!" The nurse gets frustrated and forcefully holds the patient to administer the medication over the patient’s objection. Which term best describes this action?

A nurse knows operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique should the nurse apply?

An adult says, "I have no answers," and "My opinion does not count." Which psychosocial crisis was unsuccessfully resolved for this adult?

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?