A patient fearfully runs from chair to chair crying, 'They're coming! They're coming!' The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?

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Behavioral Health Certification for Nurses Questions

Question 1 of 5

A patient fearfully runs from chair to chair crying, 'They're coming! They're coming!' The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?

Correct Answer: B

Rationale: A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.

Question 2 of 5

When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to

Correct Answer: C

Rationale: Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.

Question 3 of 5

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention?

Correct Answer: B

Rationale: The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distractor indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

Question 5 of 5

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.)

Correct Answer: A

Rationale: Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

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