Mental Health Emergencies practice questions

Answer: A) Place the patient in a safe room, secure belongings that could be used for self-harm, and begin continuous observation

When a patient discloses a suicide plan, the first nursing priority is immediate safety: remove possible means of self-harm and provide continuous observation. Assessment, consultation and home safety planning come after that.

• ACorrect. A stated plan means immediate danger. The first priority is to keep the patient from harming themselves while in the ED: remove possible means (including unsearched belongings) and never leave the patient unobserved.
• BIncorrect. A full risk assessment is needed, but the patient has already disclosed a plan. Protective measures must not wait for paperwork.
• CIncorrect. A psychiatric evaluation is appropriate, but leaving the patient unobserved in the waiting room with unsearched belongings is unsafe.
• DIncorrect. Restricting access to means at home matters for discharge planning, but it does not address the immediate risk in the department.

Answer: B) Self-neglect

An older adult who lives alone and cannot meet their own needs for hygiene, nutrition and safe housing shows signs of self-neglect, which calls for assessment and referral to social services or adult protective services.

• AIncorrect. Neglect means a caregiver or other responsible person fails to meet the older adult's basic needs. This patient has no caregiver, so the failure to meet basic needs comes from the patient.
• BCorrect. Self-neglect is an older adult's failure to provide for their own basic needs, such as hygiene, nutrition and a safe home. It calls for further assessment (including cognition and depression) and referral to social services or adult protective services according to state law.
• CIncorrect. Financial abuse is the improper use of an older adult's money or assets by someone else. Nothing here suggests another person controls the patient's money. It should still be screened for, but it is not what these findings most suggest.
• DIncorrect. Malnutrition, poor hygiene and an unsafe home are not normal parts of aging. They are safety concerns that need assessment and follow-up.

Answer: B) Delirium

• AIncorrect. Dementia develops gradually.
• BCorrect. Look for underlying causes like infection or medications.
• CIncorrect. Sudden confusion isn't normal.
• DIncorrect. The acute onset suggests delirium.

Answer: C) Emergence reactions and airway issues like laryngospasm

• AIncorrect. That isn't a concern.
• BIncorrect. That isn't the main concern.
• CCorrect. Monitor closely.
• DIncorrect. That isn't typical.

Answer: B) Neuroleptic malignant syndrome

Fever, lead-pipe rigidity, autonomic instability and confusion after starting a dopamine antagonist point to neuroleptic malignant syndrome. Treatment is to stop the drug and give aggressive supportive care, adding bromocriptine or dantrolene in severe cases.

• AIncorrect. Serotonin syndrome follows serotonergic drug exposure and usually causes hyperreflexia and clonus, with less severe rigidity. Haloperidol is a dopamine antagonist, and this patient has no clonus.
• BCorrect. Exposure to a dopamine antagonist, followed by fever, severe rigidity, autonomic instability and altered mental status, defines NMS. The nurse should expect the drug to be stopped, plus cooling, fluids and electrolyte correction. Bromocriptine or dantrolene may be added in severe cases.
• CIncorrect. Malignant hyperthermia is triggered by inhaled anesthetics or succinylcholine, and this patient has had no recent surgery or anesthesia.
• DIncorrect. Anticholinergic toxicity causes hot, dry skin and usually no marked rigidity. This patient is diaphoretic and has lead-pipe rigidity.

Answer: C) Faking symptoms on purpose for external gain

• AIncorrect. That's psychosis.
• BIncorrect. That's conversion.
• CCorrect. Examples include avoiding work.
• DIncorrect. That's panic.

Answer: A) Obtain a 12-lead ECG and assess for a medical cause

Before attributing chest symptoms to panic, the ED nurse must first rule out medical causes, starting with a 12-lead ECG. A history of panic attacks does not exclude a cardiac or other medical emergency.

• ACorrect. Panic attacks can mimic a heart attack and other medical emergencies. Cardiac, respiratory, metabolic and substance-related causes must be ruled out before the symptoms are put down to panic.
• BIncorrect. An anxiolytic may help later, but giving it first assumes the symptoms are psychiatric and can delay finding a dangerous medical cause.
• CIncorrect. Breathing techniques are a reasonable comfort measure, but they should not come before assessment for cardiac or respiratory causes of chest symptoms.
• DIncorrect. A referral may be appropriate once medical causes are excluded. A prior panic history does not prove that today's chest symptoms are panic.

Answer: A) The patient must be seen face-to-face within 1 hour of restraint initiation by a physician/licensed practitioner or a specially trained RN or PA

CMS requires a face-to-face evaluation within 1 hour when restraints are used for violent or self-destructive behavior. Monitoring must be done by trained staff at intervals set by hospital policy, and adult orders can be renewed for up to 4 hours at a time.

• ACorrect. When restraint is used for violent or self-destructive behavior, 42 CFR 482.13(e)(12) requires a face-to-face evaluation within 1 hour of starting the intervention.
• BIncorrect. Orders for violent or self-destructive behavior can be renewed for up to 4 hours at a time for adults 18 and older (2 hours for ages 9-17, 1 hour for under 9), up to a total of 24 hours.
• CIncorrect. Restraint and seclusion can be used together only if the patient is monitored continually, either face-to-face by an assigned trained staff member or by trained staff using both video and audio equipment.
• DIncorrect. Monitoring must be done by a physician, another licensed practitioner, or staff who have completed the restraint and seclusion training required by the regulation, at an interval set by hospital policy.

Answer: A) These physical complaints may be how depression presents in an older adult, so he should be screened for depression

Depression in older adults often presents with physical complaints such as fatigue, appetite loss and sleep problems rather than sadness. These symptoms overlap with aging and dementia, so the nurse should screen for depression.

• ACorrect. In older adults, depression often shows up as fatigue, appetite loss, sleep problems and physical complaints rather than reported sadness. This makes it easy to miss unless the nurse screens for it.
• BIncorrect. Sadness is often not the main symptom in older adults with depression, so denying sad mood does not rule it out.
• CIncorrect. These symptoms overlap with normal aging, which is exactly why depression in older adults is often overlooked. They should not be dismissed as normal aging.
• DIncorrect. Depression in older adults can cause cognitive symptoms and may look like dementia. Cognitive slowing does not exclude depression.

Answer: B) Hypophosphatemia

Refeeding syndrome happens when nutrition is restarted in a malnourished patient. Insulin drives phosphate, potassium and magnesium into cells, and hypophosphatemia is the hallmark. Electrolytes need close monitoring and feeding should be advanced slowly.

• AIncorrect. When feeding resumes, insulin release drives potassium into the cells, so potassium tends to fall (hypokalemia), not rise. The dysrhythmias come from low potassium and magnesium.
• BCorrect. This is refeeding syndrome. Insulin released with renewed carbohydrate intake shifts phosphate into cells and drains already depleted stores. Low phosphate is the hallmark finding, often with low potassium, low magnesium and thiamine deficiency.
• CIncorrect. Refeeding causes sodium and fluid retention, which explains the edema, but high sodium is not the defining lab abnormality.
• DIncorrect. High calcium is not a feature of refeeding syndrome. The key shifts are low phosphate, low potassium and low magnesium.