Mental Health NCLEX 30Qw/EXP

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.

1. ~ Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? (SATA) 1. Providing complete privacy when caring for the client 2. Admitting the client to a room near the nurses' station 3. Avoiding eye contact with the client while providing nursing care 4. Arranging for a security officer to be nearby and available but out of the client's sight 5. Closing the door to the client's room to ensure privacy when providing direct client care

2, 4 ~ The nurse should not isolate herself or himself with a potentially violent client. The client should be placed in a room near the nurses' station and not at the distant end of a corridor. The nurse should strive to maintain eye contract with the client as a means of therapeutic communication. A security officer should be readily available and visible to the client if there is a possibility of imminent violence. The door to the client's room should remain open when giving care.

What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety? 1. "Try not to worry so much." 2. "I can see that you are becoming upset." 3. "Everything is going to be all right; just relax." 4. "Why are you having trouble controlling your anxiety?"

The correct option is the only one that addresses the client's feelings and concerns. Avoid options that provide false reassurance and place the client's feelings on hold. Avoid options that ask, "Why?"; this non-therapeutic communication technique will increase the client's anxiety.

What is the priority nursing action when admitting a client who has just attempted suicide? 1. Ensure constant observation of the client at all times. 2. Conduct a thorough mental health assessment of the client. 3. Determine whether the client has ever attempted suicide previously. 4. Remove all potentially dangerous articles from among the client's belongings.

1. ~ The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission.

Which client behavior is indicative of negative symptoms associated with schizophrenia? (SATA) 1. Verbal communication is almost nonexistent. 2. Gross motor skills are impacted by involuntary body movements. 3. The client needs frequent redirection because of short attention span. 4. Interpersonal relationships are negatively impacted because of delusional thoughts. 5. Conversations are difficult to follow because of demonstration of loose associations of thought.

1, 3 ~ Negative symptoms refer to a diminishment or absence of characteristics of normal function. They may appear with or without positive symptoms. Restricted speech and attention deficits are examples of negative symptoms that generally respond to atypical antipsychotic medications. Positive symptoms reflect an excess or distortion of normal functions. Delusional thoughts (delusions), loose associations of thought, and bizarre behaviors such as inappropriate body movements are positive symptoms of schizophrenia.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? (SATA) 1. Restating 2. Listening 3. Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1,2,4,5 ~ Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. ~ A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1. Frequently expresses suicidal ideations 2. Leaves the day room when anyone else enters 3. Will take personal items from other clients' rooms 4. Requires constant reassurance whenever required to make a decision

3. ~ A central defining characteristic of the antisocial personality is disregard for the rights and feelings of others. Taking the belongings of others would demonstrate this characteristic. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of antisocial personality disorder.

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "It provides a negative reinforcement when the stimulus is produced."

4. ~ Aversion therapy provides a negative reinforcement when the stimulus is produced. The remaining options are characteristics of self-control therapy.

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 1. "I need you to sign a form before leaving." 2. "You will get sick if you go out in the rain." 3. "How old are you? Your father must no longer be living." 4. "Let's have a cup of coffee, and you can tell me about your father."

4. ~ The correct response acknowledges the client's comment and behavior. Allowing the client to leave after forms are signed fails to protect the client from possible harm. The remaining options do not preserve the client's dignity.

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 1. Disrupted appearance because of weight 2. Inability to feed self because of weakness 3. Pain because of an inflamed gastric mucosa 4. Nutritional imbalance because of lack of intake

4. ~ The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance since it is the basis of the condition. Although the problems identified in the other options may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.

A post-surgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? 1. Coarse hand tremor, agitation, hallucinations, and hypotension 2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3. Hypotension, stupor, agitation, headache, and auditory hallucinations 4. Fever, hypertension, changes in level of consciousness, and hallucinations

4. ~ The symptoms associated with delirium tremens (DTs) typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions. Therefore, the remaining options are incorrect.

What is the appropriate nursing intervention in dealing with a suicidal client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Promote hope and reassurance that the problems will resolve themselves.

1. ~ A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A client who is suicidal is in a state of crisis and temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. When the nurse intervenes in this situation, the nurse "takes over" for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. Once this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Therefore, the remaining options are not appropriate for this client.

A client admitted to the mental health unit after attacking his father for disturbing him at his computer, interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact? 1. "I will be back to talk with you in 15 minutes after I complete nursing rounds." 2. "You hurt your father, and you won't leave here until you can control yourself better." 3. "You have a project to save the world? I'd really like to hear about that after I finish rounds." 4. "Well, sit right down and eat your breakfast. You're not going to save the world on an empty stomach."

1. ~ The therapeutic response is one that sets limits on the client's interruptive behavior and assesses the client's ability to control his behavior. The correct response sets reasonable, attainable expectations for the client. It is not therapeutic for the nurse to support the client's delusional system. The nurse should not engage in a "playful and mothering" type of social response, which may escalate the client's behavior; nor should the nurse chastise the client for behavior that was not within the client's control.

During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech? 1. Speech is incoherent and tangential. 2. Speech is illogical and loosely associated. 3. Speech is distractible and contains flight of ideas. 4. Speech is pressured and contains clang associations.

2. ~ Loose associations are speech patterns in which there is a lack of a logical relationship between thoughts and ideas; this causes speech and thought to seem inexact, vague, unfocused, and diffuse. Incoherence is characterized by speech that cannot be understood. Tangential speech refers to an inappropriate response to a statement in which the content of the statement is disregarded. Flight of ideas is overproductive speech, characterized by the client's quickly switching from one subject to another. Clanging is a form of rhyming that is not comprehensible; a client whose speech features clanging seems to be caught up in the sound of the words.

The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? 1. Brain anomalies that are responsible for this disorder 2. Signs that indicate the client may be considering suicide 3. The importance benzodiazepines play in the management of this disorder 4. The possibility that the client will experience medication-induced tinnitus

2. ~ Suicide is the most serious concern for clients with a mood disorders. Early identification of behaviors that reflect the client's suicidal mind-set is vital to minimizing the risk of self-injury and/or death. Mood disorders are not typically a result of brain anomalies. Benzodiazepines are not the medication classification of choice for treating mood disorders. Tinnitus is not a typical side effect of antidepressant medication therapy.

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers? 1. Barbiturate use commonly results in a rush of energy. 2. Barbiturate abuse is the cause of many drug overdose deaths. 3. The primary outcome of barbiturate abuse is psychological dependency. 4. A dangerous increase in blood pressure (BP) occurs with barbiturate abuse.

2. ~ The abuse of barbiturates, a class of central nervous system (CNS) depressants, is a major cause of fatal drug overdoses. The abuse of barbiturates results in both physical and psychological dependency. Energy rushes and elevated BP result from the use of a CNS stimulant.

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit? 1. Facing the client when providing care 2. Assigning the client to a room at the end of the hall 3. Ensuring that a security officer is available at all times if needed 4. Keeping the door to the client's room open when providing care to the client

2. ~ The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not become isolated with a potentially violent client. The nurse should never turn away from the client, and the door to the client's room should be kept open. A security officer should be within immediate call in case violent behavior appears imminent.

Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions? 1. Refuses to attend group therapy 2. Asks about how to get a will notarized 3. Argues with family members during visiting hours 4. Becomes easily agitated when roommate changes the television channel

2. ~ Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite and difficulty with sleep, and a loss of interest in usual activities. The remaining options all deal with anger and "acting out" behaviors that can be associated with depression.

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? 1. Trusting the staff 2. Socializing with other clients at a holiday party 3. Making decisions about living arrangements after discharge 4. Identifying ways to minimize the tendency to be self-centered

3. ~ A central defining characteristic of the dependent personality is the inability to make decisions with excessive dependence on others. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of dependent personality disorder.

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? 1. Developing lung cancer and/or other respiratory disorders 2. Withdrawal symptoms triggering a stress-induced relapse 3. Diminishing the effectiveness of psychotropic medication 4. Developing gastrointestinal disorders, including bleeding ulcers

3. ~ Both caffeine and nicotine can inhibit the action of psychotropic medications, which are commonly prescribed for schizophrenia. Although each of the remaining options presents a risk for injury, ineffective medication therapy presents the greatest risk for injury that currently affects this client.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

3. ~ Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.

A client diagnosed with terminal cancer 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'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. ~ Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client to discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is non-therapeutic in the one-to-one relationship.

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 1. Constipation, insomnia, and hallucinations 2. Staggering gait, slurred speech, and violent outbursts 3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 4. Decreased heart rate and blood pressure and dry nose, mouth, and skin

3. ~ The client who is experiencing opioid withdrawal (such as from heroin) may experience dysphoric mood, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, diaphoresis and piloerection, runny eyes (lacrimation) and nose (rhinorrhea), yawning, low-grade fever, restlessness, insomnia, anxiety, mydriasis, and increased pulse and blood pressure. Therefore, the other options are incorrect.

Which goal addresses the therapeutic management needs of a client experiencing hallucinations? 1. Support the client through the hallucination in a caring, therapeutic manner. 2. Provide the client with insight as to why he or she is experiencing the hallucination. 3. Facilitate the client's awareness that the hallucination is not the reality of the world. 4. Help the client to ignore the hallucination through appropriate coping mechanisms.

3. ~ The goal of nursing interventions for the therapeutic management of hallucinations is to first help the client increase awareness so that he or she can distinguish between the misperception and reality. Having insight into why the hallucinations occur and possessing strategies to manage them effectively are skills needed to attain the stated goal of awareness of reality. Ignoring a hallucination is inappropriate and can be harmful. All nursing interventions should be provided with care and in a therapeutic manner; this is not a client-oriented goal but a nursing responsibility.

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. ~ The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic? 1. "You think AA is for fanatics?" 2. "It sounds as if you look for any reason to drink!" 3. "Not any one strategy for remaining sober is best for everyone." 4. "I agree. AA is definitely not for you if you find it is a trigger to drink."

3. ~ The therapeutic statement is the one that does not cause a regressive struggle between nurse and client, which would result in dispute and another drinking excuse. By allowing the client to be in control, the nurse is able to reflect on the core problem and provide an opportunity to continue with the discussion about treatment options. The nurse should avoid confrontational statements, which can result in a regressive struggle. Agreeing with the client's rationalization is non-therapeutic. When the nurse paraphrases the statement regarding fanatics, the response becomes aggressive and sarcastic.

The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? 1. "Did you know that more people identify with just what you are saying?" 2. "Which of the features that describe codependence caused you to recognize that?" 3. "Can you tell me more about that? You see yourself as being codependent with your wife?" 4. "Have you discussed your feelings with your wife? What does your wife think about what you've said?"

3. ~ This question describes the husband of an alcohol-dependent wife who is developing awareness of his codependency. Codependency consists of an individual's becoming preoccupied with the needs and concerns of another to the exclusion of his or her own needs. The therapeutic statement seeks clarification and summarizes and focuses the client on his own concerns and discoveries. When the nurse provides a social response that is non-therapeutic, it does not focus on the client's feelings. Intellectual questioning does not facilitate expression of feelings. Asking questions that are off-focus from the client's feelings are non-therapeutic because they constitute probing. The nurse will gather this information, but by gaining the trust of the client, not by probing.

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 1. "I don't believe this is true." 2. "The doctor is not talking to the mob." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the doctor wants to get rid of you?"

3. ~ When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the caseworker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member

3. ~ Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.