NCLEX mental health plan week 1

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following?

"Are you fearful and think that others may want to hurt you?"

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

The nurse notes documentation in the clients record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?

The false belief that one is being singled out for harm by others

The client is unwilling to get out of the house for fear of "doing something crazy in public. "Because of this fear, client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder? "Which answer should the nurse give to the spouse?

Agoraphobia

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task Should the nurse appropriately plan for doing this phase?

Assist with making appropriate referrals

Which nursing interventions are appropriate for a hospitalize client with mania who is exhibiting manipulative behavior? Select all that apply.

Communicate expected behaviors to the client. Follow through about the consequences of behavior in a non-punitive manner. Assist the client with developing a means of setting limits on personal behavior. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the clients record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse and expects that the RN will take which action?

Contact the primary healthcare provider

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

Conversion disorder

The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive, and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

The mother should restrict the amount of chocolate and caffeine products in the home.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse includes which action?

Use a night light and turn off the television.

The psychiatric nurse is greeted by a neighbor im a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

I cannot discuss any client situation with you.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply

Restating, listening, maintaining neutral responses, providing acknowledgment and feedback

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?

Sit beside the client in silence and verbalize occasional open ended questions.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission which would the nurse expect to note?

The client presents a harm to self.

The Nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the clients record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which will the nurse expect to note?

The client will participate in the treatment plan.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern?

The clients report of self-destructive thoughts.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in a chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment?

Weight loss

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response the Nurse?

You understand that people fear for their children, but you are feeling fairly untreated?

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

I cannot promise to keep a secret.

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. Client is at the locked exit door and shouting, "Let me out! There is nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?

Denial

A manic client announces to everyone in the day room that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the clients behavior is not appropriate, the manic client becomes verbally abusive and threatenes physical violence to the nurses aide. Based on the analysis of the situation, the nurse determines that the appropriate action should be which intervention?

Escort the manic client to his or her room.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the clients efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hyper-vigilant and anxious. The clients mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this? "The nurse should make which therapeutic response?

It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary healthcare provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

Offered to take the client to an examination room and so he or she can be treated.

The nurse is assigned to care for a client experiencing disturbed or processes. The nurse is told that the client believes that their food is being poisoned. Which communication techniques to the nurse plan to encourage the client to eat?

Open-ended questions and silence

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse and expects that the RN will take which action?

Place the client in seclusion immediately.

The nurse observes that a client is psychotic, pacing, agitated and is making aggressive gestures. The client speech pattern is rapid, and the clients affect is belligerent. Based on these observations which is the nurses immediate priority of care?

Provide safety for the client and other clients on the unit.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

Psychomotor retardation and side effects of medication

A client says to the nurse, "I'm going to die and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I am the one who's dying." Which therapeutic response should the nurse make to the client?

You're feeling angry that your family continues to hope for you to be 'cured'?