NLE Psychiatric Disorders — Mood Disorders: Depression and Bipolar DisorderExam Answer Templates

Marks

1

Topic

Major Depressive Disorder — Signs and Symptoms

Difficulty

easy

Template Id

T1

Examiner Tip

Examiners want the exact clinical term and its precise meaning. One crisp, accurate sentence earns the full mark — do not pad with unnecessary sentences for a 1-mark item.

Model Answer

Anhedonia is the loss of interest or pleasure in activities that were previously enjoyable. It is a hallmark symptom of Major Depressive Disorder (MDD).

Question Type

very_short_answer

Answer Structure

• Line 1: Define anhedonia clearly and correctly [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'sadness' or 'depression' as the definition — these are not synonyms for anhedonia
• Vague answers such as 'not feeling happy' without specifying the clinical meaning
• Leaving out the connection to MDD when context demands it

Key Phrases To Include

• loss of interest
• loss of pleasure
• previously enjoyable activities
• Major Depressive Disorder

Marks

1

Topic

Major Depressive Disorder — Diagnostic Criteria

Difficulty

easy

Template Id

T2

Examiner Tip

Memorize SIG E CAPS perfectly — it is a frequently tested recall item. In a 1-mark question, accuracy of the mnemonic expansion is what earns the mark.

Model Answer

The mnemonic is SIG E CAPS: Sleep disturbance, Interest loss (anhedonia), Guilt/worthlessness, Energy decrease, Concentration difficulty, Appetite/weight change, Psychomotor changes, Suicidal ideation.

Question Type

very_short_answer

Answer Structure

• Line 1: State the mnemonic 'SIG E CAPS' [0.5 mark]
• Line 2: Identify what each letter represents [0.5 mark — must get majority correct]

Scoring Breakdown

Common Mark Deductions

• Stating the mnemonic but leaving out 3 or more of the components
• Confusing 'S' for only 'suicidal' and omitting 'sleep'
• Writing generic symptoms not in the mnemonic

Key Phrases To Include

• SIG E CAPS
• Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor
• Suicidal ideation

Marks

2

Topic

Pharmacology — Lithium as Mood Stabilizer

Difficulty

easy

Template Id

T3

Examiner Tip

NLE pharmacology questions on lithium almost always test these exact numbers. Memorize 0.6–1.2 (therapeutic), 1.5 (toxicity starts), and 2.0 (severe) — writing all three shows mastery even if only two are required.

Model Answer

The therapeutic serum level of lithium carbonate is 0.6–1.2 mEq/L for maintenance therapy. Lithium toxicity begins when the serum level exceeds 1.5 mEq/L. Levels above 2.0 mEq/L indicate severe toxicity and are life-threatening.

Question Type

short_answer

Answer Structure

• Line 1: State the therapeutic range — 0.6 to 1.2 mEq/L [1 mark]
• Line 2: State the toxicity threshold — above 1.5 mEq/L [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing approximate ranges without specific numbers (e.g., 'around 1 mEq/L') — no marks awarded for vague values
• Confusing the therapeutic range with the toxic range
• Omitting the unit mEq/L

Key Phrases To Include

• 0.6–1.2 mEq/L
• therapeutic range
• toxicity above 1.5 mEq/L
• severe toxicity above 2.0 mEq/L
• narrow therapeutic index

Marks

2

Topic

Bipolar Disorder — Types and Differentiation

Difficulty

medium

Template Id

T4

Examiner Tip

The key distinguishing phrase for Bipolar II is 'never a full manic episode.' Examiners specifically test whether you know that hypomania is milder and does not require hospitalization. Always include this point.

Model Answer

Bipolar I Disorder is characterized by at least one full manic episode (abnormally elevated or irritable mood lasting at least one week, causing marked impairment or requiring hospitalization). Bipolar II Disorder is characterized by at least one hypomanic episode (a milder, shorter elevation not causing marked impairment) and at least one major depressive episode — a person with Bipolar II has never had a full manic episode.

Question Type

short_answer

Answer Structure

• Line 1: Define Bipolar I — requires at least one FULL manic episode [1 mark]
• Line 2: Define Bipolar II — hypomania plus major depression, NEVER full mania [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying Bipolar II is 'less severe bipolar' without specifying the distinction between mania and hypomania
• Failing to state that a person with Bipolar II has NEVER had a full manic episode
• Confusing hypomania with dysthymia

Key Phrases To Include

• full manic episode
• at least one week
• hospitalization
• marked impairment
• hypomanic episode
• milder
• no full mania in Bipolar II
• major depressive episode

Marks

2

Topic

Bipolar Disorder — Nursing Management of Mania

Difficulty

medium

Template Id

T5

Examiner Tip

The phrase 'high-calorie finger foods' is the expected NLE answer for the manic client's nutritional management. Examiners look for this specific term. Generic answers like 'give nutritious food' will not score.

Model Answer

The nurse should offer high-calorie finger foods (such as sandwiches, fruits, or nutritious snacks) and portable fluids that the client can consume while moving or standing, since manic clients cannot sit still long enough to eat a full meal. The nurse should also monitor for signs of dehydration and exhaustion, as the client's hyperactivity places them at risk for these physiologic complications.

Question Type

short_answer

Answer Structure

• Line 1: Intervention — offer high-calorie finger foods and portable fluids [1 mark]
• Line 2: Rationale — manic client cannot sit; prevent dehydration and exhaustion [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'encourage the client to eat' without specifying the TYPE and FORM of food
• Omitting the rationale — stating what to do without explaining why loses 1 mark
• Suggesting a structured dining schedule without acknowledging that the manic client cannot comply with it

Key Phrases To Include

• high-calorie finger foods
• portable fluids
• hyperactivity
• cannot sit still
• dehydration
• physical exhaustion
• manic episode

Marks

3

Topic

Pharmacology — MAOIs and Tyramine Interaction

Difficulty

medium

Template Id

T6

Examiner Tip

This is a 3-part question: foods, mechanism, consequence. Allocate one clear sentence to each part. Examiners give marks separately for each component — do not combine them into one vague paragraph.

Model Answer

A client taking an MAOI must avoid the following high-tyramine foods: (1) aged cheeses (e.g., cheddar, parmesan), (2) cured or smoked meats (e.g., salami, hotdog), (3) fermented soy products (e.g., soy sauce, miso), and (4) tap or draft beer and red wine (e.g., Chianti). The danger is that MAOIs block the enzyme monoamine oxidase, which normally breaks down tyramine in the gut and liver. When tyramine accumulates, it triggers massive norepinephrine release, causing a life-threatening hypertensive crisis — presenting with severe occipital headache, palpitations, neck stiffness, and sharply elevated blood pressure that can lead to stroke or death if untreated.

Question Type

short_answer

Answer Structure

• Lines 1–4: Name four specific high-tyramine foods to avoid — 1 mark for listing 4 correct foods [1 mark]
• Line 5: Explain the mechanism — MAOIs block tyramine breakdown, leading to tyramine accumulation [1 mark]
• Line 6: Explain the consequence — hypertensive crisis with severe headache, high BP, palpitations, neck stiffness; potentially fatal [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing generic categories without examples (e.g., 'fermented foods' without naming specific foods)
• Explaining the danger as 'serotonin syndrome' instead of hypertensive crisis — these are different emergencies
• Naming fewer than 4 specific foods
• Omitting the mechanism (enzyme inhibition) and writing only the consequence

Key Phrases To Include

• tyramine-rich foods
• monoamine oxidase inhibitor
• tyramine accumulation
• norepinephrine release
• hypertensive crisis
• severe occipital headache
• elevated blood pressure
• palpitations
• aged cheese
• cured meats
• fermented soy
• red wine

Marks

3

Topic

Pharmacology — Serotonin Syndrome

Difficulty

hard

Template Id

T7

Examiner Tip

Organize your answer around three distinct domains: mental, autonomic, neuromuscular. Examiners check for all three. If you only list tremor and confusion, you lose the autonomic mark.

Model Answer

Serotonin syndrome is a potentially life-threatening condition caused by excess serotonergic activity in the nervous system, most commonly resulting from combining two or more serotonergic drugs — for example, an SSRI with an MAOI, or an SSRI with tramadol or St. John's wort. The three hallmark clinical manifestations are: (1) mental status changes — agitation, confusion, or restlessness; (2) autonomic instability — hyperthermia (high fever), tachycardia, diaphoresis (excessive sweating), and labile blood pressure; and (3) neuromuscular abnormalities — tremor, hyperreflexia, myoclonus, clonus, and muscle rigidity. Priority nursing management is to STOP the offending drug(s) immediately, provide supportive care (cooling measures, IV fluids, cardiac monitoring), and administer a serotonin antagonist (cyproheptadine) as ordered.

Question Type

short_answer

Answer Structure

• Line 1: State the cause — excess serotonin from combining serotonergic drugs (e.g., SSRI + MAOI) [1 mark]
• Lines 2–4: State three manifestations — mental status changes, autonomic instability, neuromuscular abnormalities [1 mark]
• Line 5: Priority management — STOP offending drug, supportive care, cyproheptadine [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing serotonin syndrome with hypertensive crisis (MAOI + tyramine) — these are different emergencies with different management
• Listing only one or two manifestations instead of all three domains
• Omitting the word 'immediately' when describing stopping the drug — urgency matters
• Not naming cyproheptadine as the antidote

Key Phrases To Include

• excess serotonergic activity
• SSRI combined with MAOI
• agitation
• hyperthermia
• hyperreflexia
• clonus
• autonomic instability
• stop the offending drug
• cyproheptadine
• supportive care

Marks

3

Topic

Suicide Risk Assessment and Precautions — MDD

Difficulty

medium

Template Id

T8

Examiner Tip

Any NLE question involving a client who expresses hopelessness or that 'life is not worth living' is a HIGH PRIORITY suicide risk question. Always begin with ASSESSMENT (asking directly), then SAFETY (remove means, observe), then THERAPEUTIC CARE. Wrong sequencing costs marks.

Model Answer

The priority nursing action is immediate suicide risk assessment. The nurse should ask directly: 'Are you thinking of killing yourself?' to assess for suicidal ideation, a specific plan, and available means. If risk is high, initiate one-to-one continuous observation and remove or secure potential means of self-harm (sharps, cords, medications, belts). The nurse should maintain a therapeutic relationship — spending short, frequent time with the client, using active listening and a non-judgmental approach, without offering false reassurance. Basic physiologic needs (nutrition, hydration, hygiene, sleep) must be addressed through structured assistance, since the client may lack energy for self-care. The client should NOT be left alone; suicidal disclosures must not be kept secret and must be communicated to the healthcare team.

Question Type

short_answer

Answer Structure

• Line 1: Priority = immediate direct suicide risk assessment — ask directly about ideation, plan, and means [1 mark]
• Line 2: Safety measures — one-to-one observation, remove potential means [1 mark]
• Line 3: Therapeutic and basic care — therapeutic relationship, meet physiologic needs, no false reassurance [1 mark]

Scoring Breakdown

Common Mark Deductions

• Starting with medication administration instead of direct assessment — assessment always comes first in the nursing process
• Recommending 'comfort the client' or 'reassure the client' as a priority instead of direct suicide risk assessment
• Failing to mention one-to-one observation for the high-risk client
• Not addressing the need to remove accessible means of self-harm

Key Phrases To Include

• direct suicide risk assessment
• suicidal ideation
• plan, method, and means
• one-to-one continuous observation
• remove means of self-harm
• therapeutic relationship
• active listening
• no false reassurance
• basic physiologic needs
• do not keep suicidal disclosures secret

Marks

3

Topic

Pharmacology — Lithium Toxicity Assessment and Management

Difficulty

hard

Template Id

T9

Examiner Tip

Case-study questions test your ability to RECOGNIZE, PRIORITIZE, and ACT. Structure your answer: (1) What is happening clinically? (2) What do you do immediately? (3) What do you assess next? This 3-step approach earns all 3 marks.

Model Answer

These signs — nausea, vomiting, diarrhea, and fine hand tremor — are consistent with early/mild lithium toxicity, which occurs when the serum lithium level exceeds 1.5 mEq/L. The nurse should first HOLD the next dose of lithium and notify the physician or health care provider immediately. The nurse should obtain a STAT serum lithium level (drawn 12 hours after the last dose for accuracy) along with renal function tests, since the kidneys excrete lithium. The nurse should assess the client for additional signs of worsening toxicity — coarse tremor, ataxia, confusion, or nystagmus — which indicate progression to moderate-to-severe toxicity (>2.0 mEq/L). Supportive measures include ensuring adequate hydration and monitoring vital signs and neurological status. The nurse should also assess for factors that may have raised the lithium level, such as low sodium intake, dehydration, diarrhea, use of NSAIDs or thiazide diuretics, or heavy sweating.

Question Type

case_study

Answer Structure

• Line 1: Identify these signs as early lithium toxicity (>1.5 mEq/L) [1 mark]
• Line 2: Immediate action — hold the dose, notify physician, obtain STAT serum lithium level [1 mark]
• Line 3: Assess for worsening signs and identify contributing factors (low sodium, dehydration, NSAIDs) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Administering the next lithium dose instead of holding it — this is a critical error in a toxicity scenario
• Failing to specify the serum lithium level threshold for toxicity
• Omitting the instruction to draw the level 12 hours after the last dose
• Not identifying contributing factors that raised the lithium level

Key Phrases To Include

• early lithium toxicity
• serum level above 1.5 mEq/L
• hold the dose
• notify physician
• STAT serum lithium level
• 12 hours after last dose
• renal function
• low sodium intake
• dehydration
• NSAIDs raise lithium levels
• coarse tremor
• ataxia
• confusion

Marks

3

Topic

Electroconvulsive Therapy — Nursing Care

Difficulty

medium

Template Id

T10

Examiner Tip

Divide your answer clearly into PRE and POST sections. Examiners mark each section separately. The single most critical post-ECT nursing action is the SIDE-LYING position — never miss this.

Model Answer

PRE-ECT NURSING CARE: The nurse ensures informed consent is obtained and documented. The client is kept NPO (nothing by mouth) after midnight or as ordered to prevent aspiration during anesthesia. Baseline vital signs are taken and documented. The client is instructed to void before the procedure. Dentures, jewelry, and hairpins are removed. A short-acting general anesthetic and a muscle relaxant (succinylcholine) are administered as ordered; atropine may also be given to reduce secretions. POST-ECT NURSING CARE: The nurse positions the client on the side (lateral position) to maintain a patent airway and prevent aspiration. Vital signs and respiratory status are monitored closely during recovery. The client is frequently reoriented to person, place, and time because transient confusion is expected. The nurse reassures the client and family that short-term memory loss is a common, usually temporary side effect of ECT.

Question Type

short_answer

Answer Structure

• Lines 1–4: Pre-ECT care — informed consent, NPO, void, remove dentures/jewelry, baseline VS, succinylcholine and anesthetic [1 mark]
• Lines 5–6: Post-ECT positioning — lateral/side-lying position to protect airway [1 mark]
• Lines 7–8: Post-ECT monitoring and reassurance — frequent reorientation, explain transient confusion and memory loss [1 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting informed consent as a pre-ECT requirement — this is both a legal and ethical obligation
• Placing the client supine (flat on back) after ECT instead of on the side — this is a critical positioning error
• Not explaining to the client that confusion and memory loss are expected and temporary
• Confusing ECT with insulin coma therapy or other historical psychiatric treatments

Key Phrases To Include

• informed consent
• NPO after midnight
• void before procedure
• remove dentures and jewelry
• succinylcholine (muscle relaxant)
• baseline vital signs
• lateral/side-lying position
• patent airway
• prevent aspiration
• frequent reorientation
• transient confusion
• short-term memory loss
• reassure client and family

Marks

5

Topic

Pharmacology — Antidepressants: SSRIs, TCAs, MAOIs

Difficulty

hard

Template Id

T11

Examiner Tip

For 5-mark questions, use clear headings (I, II, III) and organize each class with the same structure: examples, use, side effects, and nursing concerns. Consistency of format makes your answer easier to mark and signals organized clinical thinking.

Model Answer

ANTIDEPRESSANT DRUG CLASS COMPARISON: I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Examples: fluoxetine, sertraline, paroxetine, escitalopram, citalopram Clinical use priority: SSRIs are the FIRST-LINE antidepressants due to their safety profile, tolerability, and low lethality in overdose. Onset of action: 2–4 weeks for full therapeutic effect. Side effects: insomnia or sedation, nausea, headache, sexual dysfunction, and weight changes. Risk of early suicidal ideation as energy returns before mood improves. Key nursing concerns: (1) Teach the client NOT to stop abruptly (discontinuation syndrome). (2) Monitor for early suicidal ideation, especially in the first weeks of treatment. (3) NEVER combine with an MAOI — risk of serotonin syndrome. Allow a washout period of at least 2 weeks (5 weeks for fluoxetine) before starting an MAOI. II. TRICYCLIC ANTIDEPRESSANTS (TCAs) Examples: amitriptyline, imipramine, nortriptyline, clomipramine Clinical use: Effective but NO LONGER first-line due to significant side effects and high lethality in overdose. Onset of action: 2–4 weeks. Side effects: Prominent ANTICHOLINERGIC effects — dry mouth, blurred vision, constipation, urinary retention, orthostatic hypotension, and sedation. CARDIOTOXIC in overdose (causes dysrhythmias — the main cause of death in TCA overdose). Key nursing concerns: (1) DANGER IN SUICIDAL CLIENTS — because TCAs are lethal in overdose, dispense only small quantities at a time; monitor for pill hoarding. (2) Advise to rise slowly to prevent falls from orthostatic hypotension. (3) Never combine with MAOIs. III. MONOAMINE OXIDASE INHIBITORS (MAOIs) Examples: phenelzine, tranylcypromine, isocarboxazid, selegiline Clinical use: Reserved for TREATMENT-RESISTANT depression due to serious food and drug interactions. Side effects: Orthostatic hypotension, insomnia, sexual dysfunction. MAJOR RISK = HYPERTENSIVE CRISIS from tyramine-rich foods. Key nursing concerns: (1) TYRAMINE-RESTRICTED DIET IS MANDATORY — avoid aged cheeses, cured/smoked meats, fermented soy products (soy sauce, miso), sauerkraut, tap/draft beer, red wine, yeast extract, and overripe foods. (2) Hypertensive crisis (severe occipital headache, very high BP, palpitations, neck stiffness) requires emergency treatment. (3) Never combine with SSRIs, TCAs, or other serotonergic drugs — allow washout period to prevent serotonin syndrome. (4) Teach to avoid OTC decongestants containing sympathomimetics.

Question Type

long_answer

Answer Structure

• Section I: SSRIs — examples, priority as first-line, 2–4 weeks onset, side effects, no-MAOI rule, monitor for early suicidal ideation [1.5 marks]
• Section II: TCAs — examples, anticholinergic side effects, cardiotoxicity in overdose, danger in suicidal clients — dispense limited quantities [1.5 marks]
• Section III: MAOIs — examples, treatment-resistant use, tyramine-restricted diet, hypertensive crisis, washout period [2 marks — most heavily weighted due to safety implications]

Scoring Breakdown

Common Mark Deductions

• Failing to state that SSRIs are FIRST-LINE — this is the key clinical hierarchy
• Not specifying the 5-week washout for fluoxetine specifically
• Listing TCA side effects without highlighting cardiotoxicity as the major overdose danger
• Omitting specific foods in the tyramine-restricted diet section
• Confusing hypertensive crisis (MAOIs + tyramine) with serotonin syndrome (MAOIs + serotonergic drugs)

Key Phrases To Include

• SSRIs are first-line
• fluoxetine, sertraline, paroxetine
• 2–4 weeks for full effect
• never combine SSRI with MAOI
• washout period 2 weeks (5 weeks for fluoxetine)
• anticholinergic effects
• amitriptyline, imipramine
• cardiotoxic in overdose
• dispense limited quantities
• pill hoarding
• tyramine-restricted diet
• phenelzine, tranylcypromine
• hypertensive crisis
• severe occipital headache
• treatment-resistant depression
• serotonin syndrome

Marks

5

Topic

Bipolar I Disorder — Comprehensive Nursing Care (Nursing Process)

Difficulty

hard

Template Id

T12

Examiner Tip

A 5-mark ADPIE nursing care plan must be organized with clear section headers. Examiners mark each ADPIE phase separately. The most heavily weighted sections are IMPLEMENTATION (what you do) and NURSING DIAGNOSES (what you identify). Allocate most of your writing to these two sections.

Model Answer

NURSING CARE PLAN — BIPOLAR I DISORDER (MANIC EPISODE): I. ASSESSMENT Subjective data: Client reports not needing sleep, has grandiose plans, and speaks rapidly. Objective data: Elevated or irritable mood, pressured speech, flight of ideas, distractibility, decreased need for sleep (may sleep only 1–2 hours), increased goal-directed activity, impulsive spending or sexual behavior, poor grooming due to hyperactivity. Physical assessment reveals signs of dehydration and possible weight loss from inadequate food and fluid intake. Assess cognitive function, judgment, and insight into illness. II. NURSING DIAGNOSES (NANDA) 1. Risk for Injury related to impaired judgment and hyperactivity (Priority 1 — Safety per Maslow) 2. Imbalanced Nutrition: Less Than Body Requirements related to inability to sit and eat due to hyperactivity 3. Sleep Deprivation related to decreased perceived need for sleep during mania 4. Impaired Social Interaction related to intrusive and manipulative behavior 5. Ineffective Coping related to altered thought processes and impaired judgment III. PLANNING - Client will remain free from injury throughout hospitalization. - Client will consume adequate caloric and fluid intake each day. - Client will achieve 6–8 hours of sleep per night. - Client will demonstrate decreasing hyperactivity with pharmacological management. IV. IMPLEMENTATION (NURSING INTERVENTIONS) Safety and Environment: Reduce environmental stimulation — assign a quiet room away from high-traffic areas; minimize visitors and noise. Set firm, consistent, non-punitive limits on intrusive or manipulative behavior. Nutrition and Hydration: Offer high-calorie finger foods (sandwiches, fruits, granola bars) and fluids the client can carry while moving; monitor intake and output daily. Sleep: Establish a structured sleep-rest routine; minimize stimulation at night; administer prescribed mood stabilizers and sedatives as ordered. Pharmacological: Administer prescribed mood stabilizer (lithium carbonate) and/or atypical antipsychotic for acute mania. Monitor lithium serum levels (therapeutic: 0.6–1.2 mEq/L); observe for signs of toxicity. An antipsychotic or benzodiazepine may be used for acute behavioral control while lithium takes effect (1–3 weeks). Protective Measures: Prevent consequences of impaired judgment — limit access to finances, monitor for unsafe sexual behavior, and restrict unsafe activities. Therapeutic Relationship: Approach calmly, use short direct communication, channel energy into safe non-competitive activities. V. EVALUATION - Client has sustained no physical injury. - Client has consumed adequate nutrition and fluids. - Client demonstrates improved sleep patterns. - Client's mood and behavior are stabilized as evidenced by decreased pressured speech and improved impulse control. - Serum lithium level is within therapeutic range. Philippine context: Nursing care is delivered within the framework of the Mental Health Act (RA 11036), which mandates humane treatment and protects the rights of persons with mental health conditions. Informed consent and voluntary admission principles are followed as required by law.

Question Type

long_answer

Answer Structure

• Section I: Assessment — subjective and objective data, physical assessment findings [1 mark]
• Section II: At least 2–3 NANDA nursing diagnoses with Maslow prioritization [1 mark]
• Section III: Planning — measurable goals/expected outcomes [0.5 mark]
• Section IV: Implementation — environmental, nutritional, pharmacological, protective interventions with rationale [2 marks]
• Section V: Evaluation — measurable outcomes and lithium level check [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting the ADPIE structure — jumping straight to interventions without assessment loses marks
• Failing to list NANDA diagnoses — just describing the problem in lay terms is not accepted
• Not applying Maslow's hierarchy — Risk for Injury must be prioritized FIRST
• Omitting lithium therapeutic level numbers in the pharmacology section
• Not mentioning RA 11036 when the question involves psychiatric admission in the Philippines
• Writing vague outcomes like 'client will feel better' instead of measurable, observable outcomes

Key Phrases To Include

• risk for injury
• imbalanced nutrition
• sleep deprivation
• NANDA nursing diagnoses
• Maslow prioritization
• reduce environmental stimulation
• firm consistent limits
• high-calorie finger foods
• lithium carbonate
• therapeutic level 0.6–1.2 mEq/L
• atypical antipsychotic for acute mania
• pressured speech
• flight of ideas
• impaired judgment
• RA 11036 Mental Health Act
• humane treatment

Marks

2

Topic

Pharmacology — Lithium: Sodium Interaction and Patient Teaching

Difficulty

medium

Template Id

T13

Examiner Tip

The physiologic mechanism (sodium-lithium renal competition) is worth 1 full mark. Always explain the WHY before the WHAT to teach. Examiners reward pathophysiological reasoning, not just lists.

Model Answer

Lithium is handled by the kidneys in the same way as sodium. When sodium levels in the body are LOW (due to low-salt diet, dehydration, vomiting, diarrhea, diuretics, or heavy sweating), the kidneys try to compensate by conserving sodium — and because lithium is treated similarly to sodium, the kidneys also reabsorb more lithium. This causes lithium to accumulate in the blood, raising the serum level above the therapeutic range (0.6–1.2 mEq/L) and toward the toxic level (>1.5 mEq/L). Nursing Teaching: Maintain a CONSISTENT normal sodium intake — do not go on crash diets or suddenly reduce salt. Drink adequate fluids (approximately 2–3 liters per day). Be cautious in hot weather and during heavy exercise (due to sweat-related fluid and sodium loss). Avoid NSAIDs and thiazide diuretics, which can also raise lithium levels. Report signs of toxicity immediately (nausea, vomiting, tremor, drowsiness).

Question Type

short_answer

Answer Structure

• Line 1: Explain the mechanism — lithium follows sodium; when sodium is low, kidneys reabsorb more lithium → lithium rises [1 mark]
• Line 2: Teaching points — consistent salt intake, 2–3 L/day fluids, avoid NSAIDs/thiazides, caution in heat [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating that 'sodium interferes with lithium' without explaining the renal mechanism
• Failing to include the specific fluid recommendation of 2–3 liters per day
• Not mentioning NSAIDs and thiazide diuretics as drugs that raise lithium levels
• Omitting teaching about hot weather and exercise

Key Phrases To Include

• kidneys handle lithium like sodium
• low sodium causes lithium reabsorption
• serum lithium rises
• toxicity above 1.5 mEq/L
• consistent sodium intake
• 2–3 liters of fluid per day
• avoid NSAIDs
• avoid thiazide diuretics
• caution in hot weather
• heavy sweating

Marks

1

Topic

Suicide Risk Assessment — Warning Signs

Difficulty

medium

Template Id

T14

Examiner Tip

The 'sudden calm' warning sign is a high-yield NLE item that many students miss. Examiners specifically test whether you know that a paradoxical improvement in mood can mean the client has made the decision to act. Always include this.

Model Answer

Three warning signs of imminent suicide risk in a depressed client are: (1) giving away prized personal possessions, (2) a sudden calm or improvement in mood after a period of deep depression — which may indicate the client has made a decision to act, and (3) expressing a specific plan, method, and available means for self-harm.

Question Type

very_short_answer

Answer Structure

• List 3 distinct, specific warning signs clearly — each warning sign earns partial credit [1 mark total for 3 correct signs]

Scoring Breakdown

Common Mark Deductions

• Listing generic signs of depression (crying, sadness) instead of WARNING SIGNS of imminent suicide
• Listing only one or two warning signs when three are specifically requested
• Writing 'client seems sad' or 'hopelessness' — these are depressive symptoms, not specific suicide warning signs

Key Phrases To Include

• giving away prized possessions
• sudden calm or lift in mood after depression
• specific plan, method, and means
• saying goodbye
• making a will
• previous suicide attempt

Marks

5

Topic

MDD — Integrated Nursing Care: Safety, SSRI Pharmacology, Therapeutic Communication, Family Teaching

Difficulty

hard

Template Id

T15

Examiner Tip

This case study tests multiple competencies at once: communication, pharmacology, safety, and legal knowledge. Allocate your writing proportionally — do not write 80% about medication and 20% about everything else. Use subheadings (Assessment, Diagnoses, Planning, Implementation, Evaluation) to organize your answer and signal structured clinical thinking.

Model Answer

NURSING RESPONSE AND MANAGEMENT FOR MDD CLIENT ON SSRI: I. ASSESSMENT AND THERAPEUTIC COMMUNICATION WITH FAMILY The nurse should begin by validating the family's concern and educating them. Explain that SSRIs such as fluoxetine have a DELAYED ONSET of action of 2–4 weeks — the client will not feel the full therapeutic effect immediately. However, the nurse must also alert the family to a critical danger period: as the client's energy begins to improve BEFORE their mood fully lifts, the risk of acting on suicidal thoughts may actually INCREASE in the early treatment phase. Direct assessment of the client for current suicidal ideation, plan, and means is the PRIORITY action. II. PRIORITY NURSING DIAGNOSES 1. Risk for Suicide related to hopelessness, depressive disorder, and early medication phase (PRIORITY — Maslow: safety) 2. Self-Care Deficit (bathing, feeding, grooming) related to psychomotor retardation and low energy secondary to MDD 3. Imbalanced Nutrition: Less Than Body Requirements related to anorexia and decreased appetite in depression III. PLANNING — EXPECTED OUTCOMES - Client will remain free from self-harm throughout the treatment period. - Client will consume at least 50–60% of meals each day. - Client will participate in assisted hygiene activities. - Client will verbalize an understanding of the need to continue fluoxetine even before feeling its effects. IV. IMPLEMENTATION Safety (Priority 1): Perform and document ongoing suicide risk assessment. Implement appropriate observation level (up to one-to-one for high risk). Remove or secure potential means of self-harm. Ensure the client does not hoard fluoxetine tablets — dispense as ordered and monitor. Nutrition and Self-Care: Assist the client with hygiene and grooming without rushing. Offer small, frequent, preferred meals in a calm environment; document intake. Do not use false reassurance such as 'You'll be fine soon' — instead, use empathic statements: 'I can see how hard things feel right now. We are here with you.' Therapeutic Relationship: Spend short, frequent time with the client. Use a calm, non-judgmental approach. Accept silence and avoid pressuring conversation. A silent, accepting presence communicates worth to the depressed client. Family Teaching: Educate the family that (1) SSRIs take 2–4 weeks for full effect; (2) the client should NOT stop the medication once started; (3) they should monitor for any talk of suicide, giving away possessions, or sudden improvement in mood during the early treatment phase — and report these immediately; (4) medication side effects such as nausea or initial insomnia may occur and are usually manageable. Pharmacological: Administer fluoxetine as ordered. Do not combine with any MAOI. Teach the client not to stop the drug abruptly. V. EVALUATION - Client has sustained no self-harm. - Client is consuming adequate nutrition and accepting assisted hygiene. - Family demonstrates understanding of the delayed medication effect and warning signs to report. - Client reports a gradual improvement in energy and mood after 2–4 weeks. - No drug interactions or adverse effects are noted. Philippine Context: Under RA 11036 (Mental Health Act), the client has the right to be informed of their treatment and to participate in care decisions. The nurse, under RA 9173 (Philippine Nursing Act of 2002), is responsible for carrying out all safe nursing interventions and maintaining therapeutic boundaries in psychiatric care.

Question Type

case_study

Answer Structure

• Part 1: Therapeutic communication — validate family concern, explain 2–4 week onset, WARN about early suicide risk as energy returns [1 mark]
• Part 2: NANDA nursing diagnoses — at least 2 correct, with Risk for Suicide as priority [1 mark]
• Part 3: Interventions — safety/observation, SSRIs not abruptly stopped, nutritional support, no false reassurance, therapeutic relationship principles [2 marks]
• Part 4: Family teaching + Evaluation + Philippine legal framework (RA 11036, RA 9173) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Reassuring the family that 'everything will be fine in 2–4 weeks' — this misses the critical suicide risk warning about the early treatment period
• Not identifying Risk for Suicide as the FIRST and PRIORITY nursing diagnosis
• Omitting the instruction not to stop fluoxetine abruptly
• Not including any Philippine legal framework reference
• Using false reassurance in the therapeutic communication section — this is a nursing error
• Focusing entirely on medications without addressing the family's immediate concern about self-care

Key Phrases To Include

• SSRIs take 2–4 weeks
• risk of suicide increases as energy returns
• Risk for Suicide — priority nursing diagnosis
• Maslow: safety first
• one-to-one observation
• remove means of self-harm
• do not stop fluoxetine abruptly
• do not use false reassurance
• short frequent contacts
• empathic presence
• therapeutic relationship
• family teaching on warning signs
• sudden calm after depression
• giving away possessions
• RA 11036
• RA 9173