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EHPLE Psychiatric Nursing - independent subject foundations study materials
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EHPLE Psychiatric Nursing - independent subject foundations practice questions

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Question 1Psychiatric assessment, descriptive psychopathology and formulation

During a mental status examination (MSE), a psychiatric nurse tests a patient's attention and concentration by asking them to subtract 7 from 100 serially. Under which component of the MSE should these findings be documented?

  1. Thought content
  2. Sensorium and cognitive functioning Correct answer.
  3. Perceptual disturbances
  4. Insight and judgment

Explanation

Serial subtractions, digit span tests, and spelling words backward evaluate sustained attention, concentration, and working memory, which are core domains of sensorium and cognitive functioning. Documenting these objective measures allows clinicians to detect delirium, dementia, or severe cognitive disruption.

Question 2Psychiatric assessment, descriptive psychopathology and formulation

A 24-year-old patient reports hearing two voices arguing about his personal hygiene when no one else is present in the room. Which psychopathological phenomenon does this clinical finding represent?

  1. Auditory illusion
  2. Hypnagogic hallucination
  3. Auditory hallucination Correct answer.
  4. Idea of reference

Explanation

An auditory hallucination is a false sensory perception of sound occurring in the absence of an external acoustic stimulus. Running commentaries or voices arguing about the patient are classic Schneiderian first-rank symptoms characteristic of schizophrenia.

Question 3Psychiatric assessment, descriptive psychopathology and formulation

A patient with acute mania speaks rapidly, jumping from talking about his new shoes, to the price of gold in Addis Ababa, to international flight schedules, yet discernible logical connections link each transition. How should the nurse describe this thought process?

  1. Flight of ideas Correct answer.
  2. Loose associations
  3. Thought blocking
  4. Perseveration

Explanation

Flight of ideas is characterized by nearly continuous, rapid speech with abrupt shifts from one topic to another, where understandable associations or play on words still connect successive thoughts. This acceleration of thought processing is a hallmark of acute manic episodes.

Question 4Psychiatric assessment, descriptive psychopathology and formulation

A client states, 'Whenever the news anchor on Ethiopian Television clears his throat, he is sending a coded warning directly to me about my neighbors.' Which type of delusion is the client expressing?

  1. Somatic delusion
  2. Delusion of grandeur
  3. Nihilistic delusion
  4. Delusion of reference Correct answer.

Explanation

A delusion of reference involves the fixed, false belief that innocuous, coincidental events, media broadcasts, or actions of strangers have direct, tailored significance to oneself. Recognizing this symptom is critical for diagnosing delusional disorders and schizophrenia.

Question 5Psychiatric assessment, descriptive psychopathology and formulation

A patient with long-standing schizophrenia frequently invents words during conversation, such as 'flumistering' to describe the weather and 'trankulate' for walking. Which formal thought disturbance does this exemplify?

  1. Clang association
  2. Neologism Correct answer.
  3. Word salad
  4. Circumstantiality

Explanation

A neologism is a newly coined word or an idiosyncratic condensation of existing words created by a patient that possesses meaning only to the speaker. It reflects profound formal thought disorder seen in schizophrenia and severe psychotic syndromes.

Question 6Psychiatric assessment, descriptive psychopathology and formulation

When completing the mental status examination, how does the psychiatric clinician distinguish between 'mood' and 'affect'?

  1. Mood is the patient's sustained, pervasive internal emotional state, whereas affect is the clinician's observation of the patient's immediate emotional expression Correct answer.
  2. Mood changes from moment to moment based on stimuli, while affect remains stable across weeks to months
  3. Mood is evaluated purely through physical examination, while affect is assessed only by standardized laboratory questionnaires
  4. Mood refers exclusively to psychotic emotional experiences, whereas affect applies only to non-psychotic neuroses

Explanation

Mood is analogous to the prevailing climate-a sustained, pervasive, subjective emotional state reported by the patient over time. Affect is comparable to the fluctuating weather-the clinician's observable, momentary manifestation of emotion communicated via facial expression, tone of voice, and body posture.

Question 7Psychiatric assessment, descriptive psychopathology and formulation

When assessing cognitive orientation and attention in a non-literate rural Ethiopian adult, which culturally adapted modification is most clinically appropriate?

  1. Asking the patient to spell the English word 'WORLD' backward
  2. Using local market transactions, counting coins, or naming days of the week in reverse Correct answer.
  3. Requiring the patient to calculate complex compound percentages
  4. Skipping cognitive evaluation entirely because formal scoring is invalid

Explanation

Standard cognitive screening tools (like the MMSE) contain educational biases such as spelling words backward or reading text. In non-literate rural settings, utilizing culturally relevant tasks like naming days of the week backward, counting small currency units, or local seasonal markers preserves clinical validity without penalizing lack of schooling.

Question 8Psychiatric assessment, descriptive psychopathology and formulation

A patient with schizophrenia states, 'A secret organization uses electromagnetic satellite beams to place foreign thoughts directly inside my brain against my will.' Which psychopathological sign is described?

  1. Thought insertion Correct answer.
  2. Thought broadcasting
  3. Thought withdrawal
  4. Ideas of influence

Explanation

Thought insertion is the delusion that thoughts that are not one's own have been introduced into one's mind by an external agent or force. It is a Schneiderian first-rank symptom indicating severe loss of ego boundaries.

Question 9Psychiatric assessment, descriptive psychopathology and formulation

A patient surviving a severe motor vehicle crash in Oromia reports, 'I feel as though I am living outside my own body, looking down at myself like a detached spectator in a movie.' What is the clinical term for this perceptual disturbance?

  1. Depersonalization Correct answer.
  2. Derealization
  3. Autoscopy
  4. Prosopagnosia

Explanation

Depersonalization is an altered state of self-awareness characterized by feeling detached, estranged, or outside of one's own physical body, thoughts, or mental processes. It is frequently triggered by acute psychological trauma, panic, or dissociative disorders.

Question 10Psychiatric assessment, descriptive psychopathology and formulation

A 35-year-old female presents to an outpatient psychiatric clinic with lethargy, severe psychomotor retardation, cold intolerance, weight gain, and depressive affect. Which initial diagnostic investigation is essential to exclude an underlying organic endocrine etiology?

  1. Serum lithium level
  2. Thyroid function tests (TSH and Free T4) Correct answer.
  3. Electroencephalogram (EEG)
  4. Cranial computed tomography (CT)

Explanation

Hypothyroidism is a classic medical mimic of major depressive disorder, producing lethargy, psychomotor slowing, weight gain, constipation, and cold intolerance. Evaluating serum TSH and Free T4 is mandatory in any new-onset depressive presentation before committing to long-term psychotropic therapy.

Question 11Psychiatric assessment, descriptive psychopathology and formulation

In Ethiopian rural communities, an individual exhibiting trance states, shaking, speaking in altered voices, and expressing distress is frequently viewed through the cultural framework of 'Zar' spirit possession. How should a psychiatric nurse evaluate this presentation?

  1. Immediately diagnose acute paranoid schizophrenia and initiate high-dose depot antipsychotics
  2. Dismiss the patient as malingering because spiritual phenomena have no place in health centers
  3. Assess the presentation within its cultural context, distinguishing culturally normative trance experiences from distressing, impairing psychiatric disorders Correct answer.
  4. Label the presentation as irreversible neurodegenerative dementia requiring long-term institutional confinement

Explanation

In culturally sensitive psychiatric nursing, traditional idioms of distress such as 'Zar' must be carefully evaluated within their socio-cultural context. Clinicians must differentiate culturally shared spiritual beliefs from psychotic disorders or dissociative trance states that cause clinically significant subjective distress and functional impairment.

Question 12Psychiatric assessment, descriptive psychopathology and formulation

During a psychiatric intake interview, a nurse asks a patient: 'If you smelled smoke and noticed fire breaking out in a crowded cinema hall, what would you do?' Which specific cognitive parameter is being tested?

  1. Abstract reasoning
  2. Remote autobiographical memory
  3. Spatial constructional ability
  4. Practical social judgment Correct answer.

Explanation

Hypothetical scenario questions (such as reacting to a fire in a public place or finding a stamped addressed envelope) test practical social judgment-the client's capacity to assess situations realistically and formulate safe, socially appropriate, and constructive responses.

Question 13Psychiatric assessment, descriptive psychopathology and formulation

Regarding the duration criteria for diagnosing schizophrenia, what is the primary structural difference between the DSM-5 and ICD-11 classification systems?

  1. DSM-5 requires continuous signs of disturbance for at least 6 months (including 1 month of active symptoms), whereas ICD-11 requires active symptoms for at least 1 month Correct answer.
  2. DSM-5 requires only 1 week of symptoms, while ICD-11 requires 2 full years of continuous hospitalization
  3. Both systems require exactly 12 months of active untreated psychosis before a formal diagnosis can be documented
  4. ICD-11 mandates the presence of catatonia for at least 6 months, whereas DSM-5 excludes catatonia completely

Explanation

DSM-5 requires continuous signs of disturbance for at least 6 months, of which at least 1 month must involve active-phase symptoms (such as delusions, hallucinations, or disorganized speech). In contrast, ICD-11 establishes a 1-month duration threshold of core psychotic symptoms for diagnosing schizophrenia, classifying presentations under 1 month as acute and transient psychotic disorder.

Question 14Mood syndromes, longitudinal diagnosis and recovery planning

What is the core diagnostic requirement to confirm a diagnosis of Bipolar I Disorder according to psychiatric diagnostic classification?

  1. A documented history of at least three major depressive episodes and no elevated mood
  2. At least one lifetime manic episode, regardless of whether a major depressive episode has occurred Correct answer.
  3. Continuous daily cycling between depression and hypomania every 24 hours for 5 years
  4. The presence of psychotic symptoms exclusively during physical exercise

Explanation

Bipolar I disorder is defined by the occurrence of at least one manic episode in the individual's lifetime. While the vast majority of patients also experience major depressive episodes, a depressive episode is not strictly required to confirm the diagnosis of Bipolar I disorder.

Question 15Mood syndromes, longitudinal diagnosis and recovery planning

How does Bipolar II Disorder differ clinically from Bipolar I Disorder?

  1. Bipolar II requires at least one hypomanic episode and at least one major depressive episode, and has never met criteria for a full manic episode Correct answer.
  2. Bipolar II features persistent mania lasting longer than 1 month, while Bipolar I features only brief mania
  3. Bipolar II never involves any depressive episodes throughout the patient's lifetime
  4. Bipolar II is characterized by childhood-onset schizophrenia with comorbid anxiety

Explanation

Bipolar II disorder requires the occurrence of at least one hypomanic episode (lasting at least 4 consecutive days without causing marked social/occupational impairment or requiring hospitalization) and at least one major depressive episode. The occurrence of even a single full manic episode automatically reclassifies the diagnosis as Bipolar I disorder.

Question 16Mood syndromes, longitudinal diagnosis and recovery planning

According to DSM-5 criteria, a diagnosis of Major Depressive Disorder requires the presence of at least 5 of 9 depressive symptoms during a 2-week period. Which two cardinal symptoms must include at least one of them to satisfy criteria?

  1. Psychomotor agitation or auditory hallucinations
  2. Increased appetite or hypersomnia
  3. Feelings of worthlessness or poor concentration
  4. Depressed mood or loss of interest/pleasure (anhedonia) Correct answer.

Explanation

To meet diagnostic criteria for a major depressive episode under DSM-5, at least one of the two core symptoms must be present: (1) depressed mood most of the day, nearly every day, or (2) markedly diminished interest or pleasure in all or almost all activities (anhedonia), along with at least four other neurovegetative and cognitive symptoms.

Question 17Mood syndromes, longitudinal diagnosis and recovery planning

A 60-year-old severely depressed patient insists that his bowels have turned to dust, his blood has stopped circulating, and that he died three weeks ago and is an empty corpse. Which specific psychotic manifestation is described?

  1. Capgras delusion
  2. Nihilistic delusion (Cotard's syndrome) Correct answer.
  3. Erotomanic delusion
  4. Delusion of infestation (Ekbom syndrome)

Explanation

Nihilistic delusions (historically referred to as Cotard's syndrome or délire de négation) involve the fixed conviction that one has died, does not exist, has lost all internal organs, or that the entire world is destroyed. It is a severe, mood-congruent psychotic manifestation typically seen in psychotic depression.

Question 18Mood syndromes, longitudinal diagnosis and recovery planning

What is the minimum duration of chronic depressed mood required to diagnose Persistent Depressive Disorder (Dysthymia) in adult patients?

  1. At least 2 continuous years (with no symptom-free period exceeding 2 months) Correct answer.
  2. Exactly 2 weeks of uninterrupted symptoms
  3. 6 continuous months without any physical symptoms
  4. At least 10 consecutive years of daily hospitalization

Explanation

Persistent Depressive Disorder (Dysthymia) is a chronic depressive condition defined by depressed mood for most of the day, for more days than not, for at least 2 years in adults (at least 1 year in children/adolescents). During this 2-year period, any symptom-free interval must not exceed 2 consecutive months.

Question 19Mood syndromes, longitudinal diagnosis and recovery planning

Ten days after an uncomplicated delivery, a primiparous mother becomes acutely disorganized, experiences auditory hallucinations commanding her to sacrifice her newborn, and exhibits severe confusion and insomnia. What is the most critical emergency action?

  1. Reassure the family that this is mild 'postpartum blues' that will spontaneously resolve in 3 days
  2. Encourage exclusive breastfeeding and send the mother home with herbal chamomile tea
  3. Recognize postpartum psychosis as an obstetric-psychiatric emergency, ensure immediate safety of the infant, and arrange urgent psychiatric inpatient admission Correct answer.
  4. Advise the mother to increase physical household chores to distract herself from negative thoughts

Explanation

Postpartum psychosis is a psychiatric emergency occurring in approximately 1 to 2 per 1,000 deliveries, typically within the first 2 weeks postpartum. It carries high rates of infanticide and maternal suicide. Immediate hospital admission, separation of the infant from unsupervised contact with the mother, and initiation of antipsychotic/mood stabilizer therapy or ECT are critical.

Question 20Psychosis, differential diagnosis and ongoing care

In the clinical evaluation of a patient with chronic schizophrenia, which constellation of manifestations corresponds entirely to the 'negative symptoms' domain?

  1. Delusions of persecution, auditory hallucinations, and somatic delusions
  2. Avolition, anhedonia, alogia, affective blunting, and social withdrawal Correct answer.
  3. Echopraxia, waxy flexibility, and motor agitation
  4. Pressured speech, flight of ideas, and expansive grandiosity

Explanation

Negative symptoms reflect a deficit or diminution of normal emotional and behavioral functioning. The primary negative symptoms comprise avolition (lack of motivation), anhedonia (inability to experience pleasure), alogia (poverty of speech), affective flattening (blunted emotional expressiveness), and asociality (social withdrawal).

Question 21Psychosis, differential diagnosis and ongoing care

Under the DSM-5 framework, which listed psychosis-outside-mood feature is a necessary part of assessing schizoaffective disorder? This is not the complete diagnostic checklist; the overall mood/psychosis chronology and exclusions also matter.

  1. The patient must experience continuous catatonic stupor for a minimum of 12 uninterrupted months
  2. Delusions or hallucinations must be present for at least 2 weeks in the complete absence of a major mood episode (depressive or manic) Correct answer.
  3. Mood symptoms must occur during every single day of the patient's entire lifespan
  4. Psychotic symptoms must resolve completely whenever antidepressant medications are administered

Explanation

A DSM-5 schizoaffective assessment includes a period of delusions or hallucinations without a major mood episode. This necessary feature is not sufficient alone: the overall timing and proportion of mood symptoms, psychotic syndrome and relevant exclusions also need assessment.

Question 22Psychosis, differential diagnosis and ongoing care

A 45-year-old accountant maintains a fixed belief that his supervisor is tapping his office phone and sabotaging his promotion files. Aside from this specific belief, his speech is articulate, affect is normal, thought process is organized, and cognitive function and daily activities are completely preserved. What is the most likely diagnosis?

  1. Disorganized schizophrenia
  2. Major depressive disorder with psychotic features
  3. Bipolar I disorder in rapid cycling
  4. Delusional disorder Correct answer.

Explanation

Delusional disorder is characterized by the presence of one or more non-bizarre or circumscribed delusions lasting at least 1 month, where psychosocial functioning is not markedly impaired and behavior is not obviously bizarre or odd outside the specific impact of the delusion. Hallucinations, marked formal thought disorder, and affective flattening are absent.

Question 23Anxiety, obsessive-compulsive and trauma-related formulations

A 30-year-old teacher presents with chronic uncontrollable anxiety about finances, family health, and work performance for the past 8 months. She experiences muscle tension, fatigue, irritability, and restlessness. What is the most likely diagnosis?

  1. Specific animal phobia
  2. Bipolar I manic episode
  3. Post-traumatic stress disorder
  4. Generalized Anxiety Disorder (GAD) Correct answer.

Explanation

Generalized Anxiety Disorder (GAD) is characterized by excessive, persistent, uncontrollable anxiety and worry about multiple everyday events or activities for at least 6 months, accompanied by at least 3 somatic/cognitive symptoms: restlessness, fatigue, impaired concentration, irritability, muscle tension, or sleep disturbance.

Question 24Anxiety, obsessive-compulsive and trauma-related formulations

Which set of core symptom clusters defines Post-Traumatic Stress Disorder (PTSD) following exposure to a life-threatening traumatic event?

  1. Manic grandiosity, pressurized speech, and decreased need for sleep
  2. Thought insertion, thought broadcasting, and catatonic posturing
  3. Intrusion symptoms (flashbacks/nightmares), avoidance of reminders, negative alterations in cognitions/mood, and marked alterations in arousal/reactivity Correct answer.
  4. Choreiform movements, cognitive dementia, and emotional blunting

Explanation

DSM-5 and ICD-11 define PTSD through four core symptom clusters persisting for more than 1 month following trauma exposure: (1) intrusion symptoms (e.g., recurrent distressing memories, flashbacks), (2) persistent avoidance of trauma-related stimuli, (3) negative alterations in cognitions and mood, and (4) marked hyperarousal and reactivity (e.g., hypervigilance, exaggerated startle).

Question 25Anxiety, obsessive-compulsive and trauma-related formulations

Under the DSM-5 framework, which listed duration distinction is used between acute stress disorder and PTSD? This concerns diagnostic time criteria, not a guarantee that acute symptoms will resolve within that interval.

  1. ASD lasts a minimum of 10 years, whereas PTSD resolves within 48 hours
  2. ASD occurs only in children under 5 years old, while PTSD affects only geriatric patients
  3. ASD requires physical loss of a limb, while PTSD requires emotional grief only
  4. ASD symptoms occur between 3 days and 1 month following the traumatic event, whereas PTSD symptoms must persist for more than 1 month Correct answer.

Explanation

Under the DSM-5 distinction asked for here, acute stress disorder occupies the specified early duration window while PTSD requires symptoms beyond a month. These are diagnostic time boundaries, not a promise that a person's distress resolves within the acute window or that time alone establishes either diagnosis.

Question 26Anxiety, obsessive-compulsive and trauma-related formulations

A patient repeatedly visits health centers complaining of chronic abdominal and chest pain. Extensive diagnostic workups, imaging, and endoscopies reveal no organic pathology. Despite medical reassurance, the patient remains consumed by extreme anxiety, spending hours daily researching symptoms and checking their body. What is the most appropriate diagnosis?

  1. Malingering for financial gain
  2. Somatic Symptom Disorder Correct answer.
  3. Delusional disorder, somatic type
  4. Factitious disorder imposed on another

Explanation

Somatic Symptom Disorder involves one or more distressing physical symptoms accompanied by excessive thoughts, feelings, or behaviors related to the symptoms (e.g., disproportionate and persistent thoughts about seriousness, high anxiety, excessive time devoted to health concerns). The suffering is genuine and not intentionally feigned.

Question 27Substance-related, cognitive and liaison assessment

An elderly patient with no prior psychiatric history presents with acute agitation, visual hallucinations of insects crawling on the bedsheets, and fluctuating levels of consciousness. Which clinical feature most strongly points to an organic brain disorder rather than primary functional psychosis?

  1. Auditory hallucinations accompanied by paranoid delusions
  2. Presence of flat affect and severe social withdrawal
  3. Long-standing history of bizarre somatic complaints
  4. Fluctuating consciousness, acute onset, and prominent visual hallucinations Correct answer.

Explanation

Acute onset, fluctuating consciousness, disorientation, and prominent visual or tactile hallucinations are cardinal indicators of an organic delirium or medical cause. Functional psychotic disorders typically present with an insidious onset, clear sensorium, and predominantly auditory hallucinations.

Question 28Substance-related, cognitive and liaison assessment

A 48-year-old male is brought to a hospital with expansive grandiose delusions, emotional lability, progressive cognitive decline, tremors, and bilateral small pupils that constrict with accommodation but do not react to direct light. What underlying organic diagnosis must be investigated?

  1. Wilson's disease
  2. Korsakoff syndrome
  3. Neurosyphilis (General Paresis of the Insane) Correct answer.
  4. Multiple sclerosis

Explanation

General paresis (dementia paralytica) is a manifestation of tertiary neurosyphilis characterized by personality changes, grandiosity, dementia, and Argyll Robertson pupils (pupils that accommodate to near vision but do not react to light). Screening with VDRL/RPR and treponemal tests is critical.

Question 29Substance-related, cognitive and liaison assessment

At an ART clinic in Hawassa, an HIV-positive client with poor adherence presents with apathy, psychomotor slowing, forgetfulness, and impaired executive functioning without prominent cortical aphasia or agnosia. Which clinical entity is most likely?

  1. HIV-Associated Neurocognitive Disorder (HAND) Correct answer.
  2. Pick's frontotemporal lobar degeneration
  3. Primary catatonic schizophrenia
  4. Bipolar mixed state

Explanation

HIV-Associated Neurocognitive Disorder (HAND) typically manifests as a subcortical dementia characterized by mental slowing, impaired executive functioning, apathy, and motor clumsiness, occurring predominantly in individuals with advanced immunosuppression or non-adherence to ART.

Question 30Substance-related, cognitive and liaison assessment

A patient with long-standing temporal lobe epilepsy experiences a cluster of complex partial seizures, followed by a 48-hour lucid interval, after which they develop florid paranoia, auditory hallucinations, and religious delusions with clear sensorium. What is this clinical phenomenon called?

  1. Ictal delirium
  2. Post-ictal psychosis Correct answer.
  3. Interictal personality disorder (Geschwind syndrome)
  4. Simple febrile seizure

Explanation

Post-ictal psychosis is characterized by a distinctive 'lucid interval' of 24 to 72 hours following a cluster of seizures, after which polymorphic delusions, paranoia, or affective symptoms emerge while sensorium remains clear. It typically lasts days to weeks and resolves with short-term antipsychotic treatment and optimized anticonvulsants.

Question 31Substance-related, cognitive and liaison assessment

Khat (Catha edulis) is widely consumed in Ethiopia. What is the primary active psychoactive alkaloid found in fresh khat leaves that produces its amphetamine-like central nervous system stimulation?

  1. Cathinone Correct answer.
  2. Tetrahydrocannabinol (THC)
  3. Mescaline
  4. Morphine

Explanation

Fresh khat leaves contain cathinone (S-alpha-aminopropiophenone), an alkaloid chemically similar to amphetamine that stimulates the release and inhibits the reuptake of dopamine and norepinephrine, producing euphoria, alertness, insomnia, anorexia, and hypertension.

Question 32Substance-related, cognitive and liaison assessment

What is the evidence-based best practice model for delivering clinical care to clients with 'Dual Diagnosis' (co-occurring severe mental illness and substance use disorder)?

  1. Refuse all psychiatric treatment until the client achieves 5 continuous years of verified sobriety
  2. An integrated treatment model where both psychiatric and substance use disorders are addressed concurrently by the same multidisciplinary clinical team Correct answer.
  3. Sequential treatment where psychiatric illness is treated first, and substance use is referred elsewhere years later
  4. Immediate lifelong institutionalization in an isolated penal facility

Explanation

The integrated treatment model is the evidence-based gold standard for dual diagnosis. It delivers mental health and substance abuse interventions simultaneously within a single clinical team, utilizing combined pharmacotherapy, motivational interviewing, harm reduction, and psychoeducation rather than fragmented, sequential care.

Question 33Substance-related, cognitive and liaison assessment

A 72-year-old female admitted to a medical ward for severe pneumonia suddenly becomes confused, disoriented to time and place, and picks at invisible threads in the air. Her cognitive status fluctuates between lucidity during the day and intense agitation at night. What is the diagnosis?

  1. Late-onset chronic schizophrenia
  2. Delirium secondary to systemic infection Correct answer.
  3. Dissociative identity disorder
  4. Anorexia nervosa

Explanation

Delirium is an acute neurocognitive syndrome characterized by fluctuating disturbances in attention, awareness, and cognition developing over a short period (hours to days), typically triggered by an underlying general medical condition (such as systemic infection/pneumonia in older adults). Sundowning (worsening at night) is classic.

Question 34Substance-related, cognitive and liaison assessment

What is the primary medical priority in the management of a patient experiencing acute delirium in an emergency room setting?

  1. Identify and treat the underlying organic etiology while ensuring safety and optimizing hydration, oxygenation, and nutrition Correct answer.
  2. Administer high-dose lifelong mood stabilizers and transfer to a long-term asylum
  3. Initiate immediate psychoanalytic psychotherapy to uncover childhood trauma
  4. Restrict all fluids to prevent cerebral edema without taking vital signs

Explanation

Delirium is always secondary to an underlying medical cause (such as infection, metabolic disturbance, intoxication, or hypoxia). The foremost priority is identifying and treating this primary organic trigger while providing supportive care (airway, oxygenation, hydration, electrolyte balance) and environmental reorientation.

Question 35Substance-related, cognitive and liaison assessment

Which environmental nursing interventions are most effective in reducing fear and agitation in a hospitalized patient with delirium?

  1. Keep the room completely dark 24 hours a day and avoid all speaking
  2. Frequently transfer the patient between different wards to keep their senses alert
  3. Provide a quiet, well-lit room with visible clocks and calendars, encourage family presence, and assign consistent nursing staff Correct answer.
  4. Place television screens on high volume with flashing images directly in front of the bed

Explanation

Non-pharmacological management of delirium focuses on reorientation and sensory balance: maintaining a consistent, well-lit environment during the day with soft night lighting, placing visible clocks and calendars, encouraging the presence of familiar family members, and ensuring consistent nursing staff to reduce cognitive fragmentation and misinterpretations.

Question 36Psychotherapy models, learning processes and therapeutic communication

A 24-year-old has repeated self-cutting after feared rejection, rapidly shifting views of partners from idealised to hateful, chronic emptiness, intense anger, and impulsive spending. Which management plan is most appropriate as a core treatment?

  1. Structured psychotherapy such as dialectical behaviour therapy, with a collaborative crisis plan Correct answer.
  2. Indefinite high-dose benzodiazepines as the main intervention
  3. No treatment because personality disorders are untreatable
  4. Antipsychotic depot medication for all symptoms regardless of target symptoms

Explanation

Borderline personality disorder is treated primarily with structured psychological therapies such as DBT, mentalization-based therapy, or related approaches. Medication may target comorbidity or specific symptoms but is not the core treatment.

Question 37Psychotherapy models, learning processes and therapeutic communication

A patient with alcohol use disorder says, "I know drinking is damaging my liver, but it is the only way I sleep." Which response best reflects motivational interviewing?

  1. "You must stop drinking immediately or treatment will not continue."
  2. "It sounds as if alcohol feels useful in the short term, while another part of you is worried about the harm it is causing." Correct answer.
  3. "Your insomnia is irrelevant until you accept that you are addicted."
  4. "I will arrange admission today because ambivalence means you lack capacity."

Explanation

Motivational interviewing uses empathy, reflective listening, autonomy support, and exploration of ambivalence. It avoids confrontation, coercion, and premature advice-giving.

Question 38Psychotherapy models, learning processes and therapeutic communication

A man with schizophrenia hears a voice saying he is worthless. In CBT for psychosis, which therapist intervention is most consistent with the model?

  1. Tell him the voice is definitely unreal and ask him not to mention it again
  2. Explore triggers, meanings, evidence, coping responses, and alternative explanations collaboratively Correct answer.
  3. Interpret the voice as proof of unconscious sexual conflict before discussing coping
  4. Avoid discussing voices because attention to psychotic symptoms inevitably worsens them

Explanation

CBT for psychosis works collaboratively on appraisals, distress, coping, safety behaviours, and alternative explanations. It does not rely on blunt contradiction or avoidance of symptoms.

Question 39Psychotherapy models, learning processes and therapeutic communication

A 23-year-old woman with borderline personality disorder has recurrent self-harm after interpersonal crises. In dialectical behaviour therapy, what is usually the highest priority treatment target?

  1. Detailed exploration of childhood memories before any current risk work
  2. Medication adherence, because DBT is primarily a pharmacological adherence programme
  3. Avoiding discussion of self-harm to prevent reinforcement
  4. Life-threatening behaviours, analysed with chain analysis and linked to skills practice Correct answer.

Explanation

DBT prioritises life-threatening behaviours, then therapy-interfering behaviours and quality-of-life targets. Chain analysis and skills training connect triggers, vulnerabilities, behaviours, and alternatives.

Question 40Psychotherapy models, learning processes and therapeutic communication

In psychotherapy, a patient becomes intensely angry when the therapist is two minutes late and says, "You are just like my father, always abandoning me." What concept best describes this phenomenon?

  1. Thought blocking
  2. Negative reinforcement
  3. Akathisia
  4. Transference Correct answer.

Explanation

Transference refers to feelings, expectations, and relational patterns from earlier relationships being experienced in the therapeutic relationship. It can be clinically useful when handled thoughtfully.

Question 41Treatment principles, adverse effects and medication monitoring

A patient receiving haloperidol 10 mg daily for schizophrenia is observed constantly pacing the ward corridor, shifting weight from one foot to another, and complaining of an unbearable internal urge to keep moving. How should the psychiatric nurse manage this symptom?

  1. Increase the dose of haloperidol, interpreting the pacing as worsening psychotic agitation
  2. Apply physical restraints immediately to prevent exhaustion and falls
  3. Recognize akathisia and advocate for a dose reduction or initiation of propranolol Correct answer.
  4. Administer flumazenil to reverse suspected benzodiazepine toxicity

Explanation

Akathisia is a distressing subjective motor restlessness where the patient feels an irresistible compulsion to move, commonly manifesting as pacing, rocking, or foot tapping. It is an extrapyramidal side effect of dopamine antagonists, treated effectively by reducing the antipsychotic dosage or adding a lipophilic beta-blocker like propranolol or a low-dose benzodiazepine.

Question 42Treatment principles, adverse effects and medication monitoring

A patient receiving high-dose haloperidol develops severe 'lead-pipe' muscle rigidity, a temperature of 40.2 C (104.4 F), diaphoresis, blood pressure fluctuations (180/110 to 90/60 mmHg), and marked elevation in serum creatine kinase (CK). What is the primary life-saving nursing priority?

  1. Discontinue all antipsychotics immediately, initiate active external cooling, provide IV hydration, and alert the medical team for ICU transfer Correct answer.
  2. Administer additional haloperidol intramuscularly to control autonomic instability
  3. Give high-dose acetaminophen orally and wait 24 hours to monitor temperature response
  4. Apply warming blankets and administer high-dose beta-blockers

Explanation

This patient presents with classic Neuroleptic Malignant Syndrome (NMS), a life-threatening psychiatric emergency characterized by hyperthermia, extreme rigidity, autonomic instability, and elevated creatine kinase. Immediate cessation of the offending neuroleptic, aggressive hydration, external cooling, and potential administration of dantrolene or bromocriptine in an intensive care setting are essential.

Question 43Treatment principles, adverse effects and medication monitoring

Clozapine is the gold-standard treatment for treatment-resistant schizophrenia, but its clinical use requires strict mandatory laboratory monitoring. Which life-threatening adverse effect necessitates routine absolute neutrophil count (ANC) tracking?

  1. Severe acute pancreatitis
  2. Irreversible pulmonary fibrosis
  3. Agranulocytosis Correct answer.
  4. Malignant melanoma

Explanation

Clozapine carries an approximate 1% risk of drug-induced agranulocytosis (severe neutropenia), which leaves patients vulnerable to fatal systemic infections. Strict protocols mandate baseline and weekly to monthly complete blood counts with absolute neutrophil count (ANC) tracking throughout therapy.

Question 44Treatment principles, adverse effects and medication monitoring

A patient newly started on chlorpromazine stands up quickly from bed and reports dizziness, lightheadedness, and blurred vision. The nurse notes a supine blood pressure of 124/80 mmHg and a standing blood pressure of 96/60 mmHg. Which receptor blockade is responsible for this side effect?

  1. Histamine H1 receptor blockade
  2. Serotonin 5-HT2C receptor blockade
  3. Dopamine D1 receptor blockade
  4. Alpha-1 adrenergic receptor blockade Correct answer.

Explanation

Orthostatic (postural) hypotension caused by low-potency phenothiazines like chlorpromazine results from peripheral alpha-1 adrenergic receptor blockade, which prevents compensatory sympathetic vasoconstriction upon standing.

Question 45Treatment principles, adverse effects and medication monitoring

A patient taking both sertraline and tramadol presents with sudden shivering, profuse diaphoresis, hyperreflexia, bilateral ocular clonus, and agitation. Which clinical condition is most likely?

  1. Anticholinergic delirium
  2. Neuroleptic malignant syndrome
  3. Serotonin syndrome Correct answer.
  4. Opiate withdrawal syndrome

Explanation

Serotonin syndrome results from excessive serotonergic activity and is diagnosed using the Hunter criteria (hyperreflexia, inducible or ocular clonus, tremor, diaphoresis, hyperthermia, and agitation). Unlike NMS which features hyporeflexic 'lead-pipe' rigidity, serotonin syndrome is characterized by neuromuscular hyperreactivity (clonus and hyperreflexia).

Question 46Treatment principles, adverse effects and medication monitoring

Before initiating lithium therapy in a patient diagnosed with bipolar I disorder, which baseline organ function tests must the nurse ensure have been completed?

  1. Renal function tests (BUN, creatinine) and thyroid function tests (TSH) Correct answer.
  2. Serum amylase and lipase levels
  3. Pulmonary function tests and arterial blood gases
  4. Serial lumbar puncture and cerebrospinal fluid protein

Explanation

Lithium is excreted almost entirely by the kidneys and is known to cause nephrogenic diabetes insipidus, chronic tubulointerstitial nephropathy, and hypothyroidism. Baseline renal function (serum creatinine, eGFR, BUN) and thyroid function (TSH, free T4) tests, along with baseline ECG and pregnancy testing, are mandatory.

Question 47Treatment principles, adverse effects and medication monitoring

A 24-year-old female with bipolar disorder is being evaluated for mood stabilizer maintenance therapy. Why is sodium valproate generally avoided or prescribed only with rigorous contraception in women of childbearing potential?

  1. It causes immediate permanent ovarian failure within one cycle
  2. It causes severe maternal pulmonary hypertension
  3. It carries a significant risk of major congenital malformations, especially neural tube defects (spina bifida) Correct answer.
  4. It induces irreversible autoimmune aplastic anemia in female fetuses

Explanation

Sodium valproate is a potent teratogen associated with a 1% to 2% risk of neural tube defects (such as spina bifida and anencephaly), craniofacial abnormalities, and long-term neurodevelopmental deficits when taken during early pregnancy. International and Ethiopian guidelines advise avoiding valproate in women of childbearing potential unless no alternatives exist.

Question 48Treatment principles, adverse effects and medication monitoring

Through which molecular mechanism do benzodiazepines such as diazepam and lorazepam produce their anxiolytic, sedative, and anticonvulsant actions?

  1. Allosterically modulating GABA-A receptors to increase chloride channel opening frequency in the presence of GABA Correct answer.
  2. Directly opening calcium channels in the presynaptic terminal, triggering massive dopamine release
  3. Competitively blocking postsynaptic serotonin 5-HT1A receptors throughout the limbic cortex
  4. Inhibiting acetylcholinesterase, thereby increasing acetylcholine levels in the neuromuscular junction

Explanation

Benzodiazepines bind to a specific allosteric site on the GABA-A receptor complex. This enhances the receptor's affinity for gamma-aminobutyric acid (GABA), increasing the frequency of chloride channel opening, leading to neuronal hyperpolarization and central nervous system depression.

Question 49Treatment principles, adverse effects and medication monitoring

A patient with schizophrenia has been treated with olanzapine 15 mg daily for 6 months. Which cluster of metabolic laboratory parameters requires regular ongoing nursing monitoring?

  1. Serum uric acid, ESR, and rheumatoid factor
  2. Serum calcium, phosphate, and parathyroid hormone
  3. Body weight, waist circumference, fasting blood glucose, and fasting lipid panel Correct answer.
  4. Prothrombin time (PT), INR, and bleeding time

Explanation

Second-generation antipsychotics-particularly olanzapine and clozapine-carry a high risk of metabolic syndrome, including significant weight gain, dyslipidemia, insulin resistance, and new-onset type 2 diabetes mellitus. Baseline and periodic monitoring of BMI, waist circumference, fasting glucose/HbA1c, and fasting lipids is standard practice.

Question 50Treatment principles, adverse effects and medication monitoring

Which clinical scenario represents an evidence-based primary indication for considering Electroconvulsive Therapy (ECT)?

  1. Mild dysthymia responsive to outpatient supportive psychotherapy
  2. Obsessive-compulsive personality disorder without depression
  3. Isolated adjustment disorder with brief situational anxiety
  4. Severe major depression with catatonia, psychotic features, or immediate acute starvation and suicidality Correct answer.

Explanation

Electroconvulsive therapy (ECT) is the most rapidly effective somatic intervention for severe, life-threatening psychiatric conditions, particularly treatment-resistant major depression, depression with severe psychotic features, acute suicidal exhaustion, catatonia, and neuroleptic malignant syndrome.