NCLEX Mental Health

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and helping one."

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

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

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse?

"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?"

The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?

4. Within a few hours

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior that denotes repetition in which?

Actions

While the nurse is providing care, a client angrily reports to the nurse that the health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client?

"The health care provider would never lie to you."

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?

"The leader of this self-help group is the nurse or psychiatrist."

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?

"What do you mean by that?"

A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse?

"When I tell my child to do something once, I don't expect to have to repeat it."

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response?

"You don't think you can ever do anything right?"

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

1. Hallucinations 3. Delusions 4. Neologisms

A client diagnosed with schizophrenia is experiencing an acute dystonia reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply.

1. Monitor airway. 2. Notify the registered nurse (RN). 4. Remain with the client to provide support. 6. Administer a prescribed IM antiparkinsonian medication.

Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.

1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.

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.

1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgment and feedback

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which should the nurse assigned to care for the client do first?

1. Take the client to a quiet room.

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

2. Client threatened to commit suicide. 3. Client threatened to kidnap his spouse.

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

3. "My boyfriend yells and accuses me of having an affair if I am late after work." 4. "I have bruises all over my body. I am frequently clumsy and fall a lot." 1. "My husband always brings me flowers and apologizes after he hits me."

The nurse caring for a client with schizophrenia prepares to document which symptoms exhibited by the client as negative symptoms? Select all that apply.

3. Avolition 5. Anergia

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.

3. Misplacing a valuable object 5. Difficulty coming up with the right word

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

3. Request that the client perform undemanding, self-care tasks. 4. Reinforce teaching the client techniques to maintain present reality. 5. Assist the client to reestablish relationships with significant others.

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

Agoraphobia

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?

4. Evidence of the client's altered and distorted body image

A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?

Altered thought processes

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa?

A client with pneumonia

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action?

Approach the client quietly, take her to her room, and assist her in getting dressed.

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

Assist in making appropriate referrals.

Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?

Aversion therapy

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action?

Call the nursing supervisor.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?

Client involvement in goal setting

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which symptoms or behaviors as requiring immediate intervention?

Constant physical activity and poor oral intake

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?

Conversion disorder

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

Denial

The nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which signs and symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?

Develops a relationship to help reduce the frequency of the delusions

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.

The nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which issue?

The parameters of the relationship

A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse should focus the initial data collection on which information?

The presence of existing suicidal thoughts

An agoraphobic client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. To meet the client's nutritional needs, the nurse plans which action?

To provide small frequent meals

The nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety to the clients will be provided at which times?

Weekends

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 the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

Weight loss

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while?"

The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present?

Amenorrhea

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?

Distancing

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?

Do you recall needing to be hospitalized because you stopped your medication?"

The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate?

Encourage the client to stay and ask the client what she is feeling.

When caring for a client who has been raped, which intervention should the nurse implement during the examination?

Explaining procedures to be completed and why the procedures are necessary

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

Incoordination 4. Mental confusion 5. Muscle hyperirritability

A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility. The nurse should use which piece of information when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.

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 client's 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

The nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse take?

Interrupt the client and offer to take her for a walk.

The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem?

Maintain a well-groomed appearance.

The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?

Makes excuses for not leaving the house

A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with which?

Somatization disorder

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

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

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

The nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feel regret?"

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse should be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time?

"You sound very unhappy. Are you thinking of harming yourself?"

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?

"You're feeling angry that your family is hoping for a cure?"

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior?

Improvement

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a DVD and a cherished autographed picture of the performer.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?

Hypertension, disorientation, hallucinations

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?

"I can see that you are upset about this. Let's talk about this some more."

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?

"I can see that you're upset. I'm willing to listen."

The nurse is reviewing the discharge plan with a female teenager with anorexia nervosa and reinforces the importance that the teenager attends a meeting of the local chapter of Anorexia Nervosa and Associated Disorders. Which response by the teenager indicates that she will likely be compliant with this plan?

"I'm going to do whatever it takes to get better."

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action?

Privately confront the client with reality.

The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term?

Psychodrama

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?

Quietly approach the client, escort her to her room, and assist her in getting dressed.

A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. Which action should the nurse implement?

Remain with the client at all times.

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate?

Remain with the client until the anxiety decreases.

The nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which problem?

Social phobia

Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?

Stay with the client until the medication becomes effective.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand and obtain release from the hospital.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide.

A mental health nurse on the evening shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect which statement is an aspect of the client's care?

The client is in need of psychiatric treatment.

The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?

The client reports nightmares involving being stalked when alone at night.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma.

The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?

Telling a friend that this employee hates her

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?

Stay with the client at all times.

The psychiatric nurse is greeted by a neighbor in 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 is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client?

Goals and objectives

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach?

Help the client identify and examine dysfunctional thoughts and beliefs.

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the health care provider is notified.

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions to this client's medication refusal? Select all that apply.

1. Notify the health care provider. 2. Document the refusal of medication. 3. Ask the client why he is refusing the medication.