Mental Health NCLEX Questions

A nurse is assessing a client's alcohol intake as part of a routine screening examination. The client reports drinking 3 to 4 beers; five times per week. The client is being treated for depression with setraline (Zoloft) 100mg daily. Which statement by the nurse about the client's alcohol consumption is accurate? 1. A moderate amount of alcohol helps the client forget problems and can decrease depression 2. As long as the client does not exceed five drinks in a 24-hour period, alcohol intake is within normal limits. 3. Alcohol worsens depression and makes treatment of depression more difficult. 4. Alcohol is a stimulant that will help the client be more social.

3. Alcohol worsens depression and makes treatment of depression more difficult.

A client says, "I go out just about every weekend and drink pretty heavily with my friends. Does that mean that I'm dependent on alcohol?" Which is the best response by the nurse? 1. "Not necessarily. With dependence, you have a strong need to drink and feel uncomfortable if you don't." 2. "You could be dependent. Drinking every week is excessive." 3. "It sounds like you feel guilty about how much you drink." 4. "You're not dependent if you never drink to the point of intoxication."

1. "Not necessarily. With dependence, you have a strong need to drink and feel uncomfortable if you don't."

The adult child of an elderly client with depression asks the nurse why elderly people are at higher risk for developing depression. Which response by the nurse is most appropriate? 1. "Older clients have higher levels of an enzyme that slows signals to the brain, causing depression." 2. "Older clients have a higher level of a thyroid hormone that can lead to depression." 3. "Older adults have enlarged ventricles of the brain, which can lead to depression." 4. "Older adults have higher levels of chemical messengers in the brain that result in depression."

1. "Older clients have higher levels of an enzyme that slows signals to the brain, causing depression."

A manic client begins to make sexual advance towards visitors in the day room. When the nurse firmly states that this is I appropriates and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

3. Escort the client to their room, with the assistance of other staff.

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? 1. Educating clients on health promotion techniques to reduce the risk of depression 2. Performing screenings for depression at community health programs 3. Establishing rehabilitation programs to decrease the effects of depression 4. Providing support groups for clients at risk for depression

3. Establishing rehabilitation programs to decrease the effects of depression

*Aware that the manifestations of ADHD are different in girls than boys, the nurse knows her teaching has been successful when the 17-yr female client states: 1. I am now able to keep my voice down while in public. 2. I now have some tools to help me when I can't sit still. 3. I am not as prone to blame myself when I don't do something well. 4. I am not as impulsive as I used to be.

3. I am not as prone to blame myself when I don't do something well.

A nurse is assessing a client's symptoms between delirium and depression. Which symptoms of the client are unique to depression? Select all that apply. 1. Sadness 2. Disturbance in sleep patterns 3. Fluctuating levels of consciousness 4. Labile effect 5. Lack of motivation 6. Presence of hallucinations

1. Sadness 5. Lack of motivation

A nurse working in a medical-surgical nursing unit is caring for a client 3 days post-admission who has a long history of heavy alcohol abuse. For which most acute complications related to alcohol abuse should the nurse initially monitor? SELECT ALL THAT APPLY. 1. Seizures 2. Infections 3. Gastrointestinal bleeding 4. Pancreatitis 5. Delirium tremens

1. Seizures 5. Delirium tremens

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client's behavior

An experienced nurse is teaching a new nurse about establishing therapeutic relationships with clients on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with a client diagnosed with major depressive disorder? 1. Sit with the client in silence. 2. Ask the client to join others to watch a 2 hour movie. 3. Invite the client to attend an exercise class. 4. Ask the client how his or her day should be scheduled.

1. Sit with the client in silence.

A family member asks you, "As both of my siblings have schizophrenia, why are my brother's symptoms so different from my sister's? He withdraws when there is a change in his environment or routine. She starts cursing and yelling about the Mafia and the CIA when I do something that's less than perfect." Based on your knowledge, your response should address: 1. There are many differences in the presentation of schizophrenia. 2. The significance of paranoid content in the differential diagnosis of paranoid schizophrenia. 3. The typical progression of symptoms within an individual over time. 4. The effect of gender on clinical presentation in schizophrenia.

1. There are many differences in the presentation of schizophrenia.

A hospital 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 tings that I have to do right away." The client has not been dischared 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. call the nursing supervisor.

A nurse assesses a client who reports feeling full of energy in spite of being awake for the past 48 hours. Which diagnosis is the nurse likely to find documented in the client's medical record? 1) Obsessive compulsive disorder 2) Bipolar disorder/manic type 3) Bipolar disorder/mixed type 4) Korsakoff's psychosis

2) Bipolar disorder/manic type

The healthcare provider is counseling a patient who is diagnosed with depression. Which of the following statements made by a patient should the healthcare provider recognize as a sign of transference? Please choose from one of the following options. 1. "I'm glad I lost my job because now I don't have to commute." 2. "It's amazing how much you remind me of my favorite teacher." 3. "I drink so I can deal with the difficult situation at work." 4. "I may not be good looking, but I get really good grades."

2. "It's amazing how much you remind me of my favorite teacher."

A nurse teaching a student about substance abuse in older adults perceives the need for more teaching when the student states: 1. "As the baby boomer generation ages, substance abuse in adults 50 or older is expected to drastically increase." 2. "Substance abuse exacerbates certain medical problems, making them easier to diagnose." 3. "Prescription and over-the-counter drug abuse is more likely in older adults than younger adults." 4. "The consequences of substance abuse in older adults may be more critical than in younger adults."

2. "Substance abuse exacerbates certain medical problems, making them easier to diagnose."

(BRITTANY) A child is being seen at the clinic for an attention deficit hyperactivity disorder (ADHD) assessment. What symptoms would the nurse expect to find? Select all that apply. A. excessive climbing and running B. excessive fidgeting C. pouting behaviors D. cannot wait to take turns E. easily distracted

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(CAROLINE) The nurse is providing care for a pregnant woman. The woman states that "a few family members have ADHD and I am wondering if there is anything I can do to reduce the chance of my child having it?" the nurse knows which of the following are prevention strategies for ADHD. (select all that apply). 1. Avoiding drugs and alcohol during pregnancy 2. Limit TV exposure when child is born 3. Have consistent behavior rules when child is born 4. Play classical music for fetus during pregnancy 5. There are no strategies to prevent ADHD at this time

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(CHEETO) The nurse cares for an elderly client who appears full alert and oriented. As it gets later in the day, the nurses notices the client becoming increasingly confused and agitated. It would be MOST appropriate for the nurse to take on which of the following actions? 1.) Reorient the client, and then turn on the lights and television to distract the client from to distract the client from his confusion. 2.) Encourage the client's alert roommate to talk with the client. 3.) Tell the client he is at home in his own bed to get him to settle down and go to sleep. 4.) Reorient the client, pull the shades down, shut the lights and television off, and promote a quiet environment.

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(COLLEEN) A client moved to Minnesota from Texas to be closer to her grandchildren. She is happy to be around them however she feels very moody. The client is having trouble sleeping and states feeling fatigued with low energy. Winters are worse as she hates the cold and the fact that it is dark at 4pm. She just can't seem to get motivated to go out at night and asks the nurse "what's wrong with me?" The client is experiencing... 1. Insomnia 2. Major depressive episode 3. Seasonal affective disorder 4. Dysthymic disorder (persistent depressive disorder)

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(DANIELLE) The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care ? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

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(GAYLE) A client diagnosed with an anxiety disorder tells a nurse that being in crowds creates thoughts of losing control and the need to hurriedly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client's symptoms of anxiety? 1) Cognitive behavioral therapy (CBT) 2) Electroconvulsive therapy (ECT) 3) Family systems therapy 4) Psychoanalytical therapy

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(JACQUELINE) Which of these clinical manifestations would the healthcare provider anticipate observing in a patient experiencing an acute panic attack? Select all that apply. A. Decreased thyroid B. Bronchoconstriction C. Elevated blood pressure D. Dilated pupils E. Hypoglycemia

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(JEFF) A male patient in the psychiatric unit experiencing a state of mania is walking the halls completely naked. How should the nurse respond initially? (Select all that apply) 1. Tell the patient he will be secluded if he does not get dressed. 2. Confront the patient and insist he get dressed. 3. Withhold family visits due to inappropriate behavior. 4. Encourage the patient to get dressed. 5. Ask the other patients to go to their rooms. 6. Quietly escort the patient to his room.

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(KARLEEN) The friend of a client with depression and suicidal ideation asks the nurse, "How should I act around her?" Which response by the nurse is best? A. "Try to cheer her up." B. "Be caring and genuine." C. "Control your expressions." D. "Avoid asking how she is feeling."

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(KATELYN) A nurse is collaborating with the school and parents of a child with ADHD on strategies and interventions for their child when at school. The nurse educates the parents and confirms the parents have reached proper understanding of the interventions when they provide which statement? a. "We understand our child might be fidgty, loud, and inappropriate at times but it is not helpful to set consequences for his inappropriate behavior" b. "We will encourage him to have as much structure as possible when at school throughout the day" c. "The teacher should remove him from the classroom every time he is being disruptive" d. "We want our son to have different teachers and activities each day so he doesn't get bored"

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(LEANNE) Which statement made by a severely anxious client to the nurse during a psychiatric admission assessment would indicate the possibility of post-traumatic stress disorder (PTSD)? 1. "I keep reliving the rape" 2. "I'm afraid to go out in public" 3. "I keep washing my hands over and over" 4. "My legs feel weak most of the time"

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(MICAELA) The nurse is planning care for a 4-year-old child with attention deficit hyperactivity disorder (ADHD). The nurse selects risk for injury as a nursing diagnosis based on which statement made by the client's parent? A. "My child just never sits down anymore." B. "I found my child up at the top of a tree this week." C. "My child doesn't listen very well to me." D. "My child seems to daydream a lot."

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(MIKAYLA) A client is admitted to the mental health unite with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days. 2. Identification of physical activities that will provide exercise. 3. No socializing activities. until the client asks to participate in milieu. 4. A structured program of activities in which the client can participate.

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(RYAN) A nurse is assessing a patient that has a history of suicidal thoughts and actions. The patient is in the clinic today on unrelated terms. However, the patient states "Sometimes, I think it would be easier to disappear." What is the NEXT action the nurse should do? A. Ask if they have a plan to take their own life? B. Ask them to tell you more about their statement regarding disappearing. C. Disregard and continue assessment. D. Immediately implement a 72 hour hold.

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(RYAN) If you are working with a nurse that has been not quite the same lately, what are the early warning signs of withdrawal? (Select all that apply): a. Tremors b. Restlessness c. Watery eyes d. Binge eating e. Complains of exhaustion after a long day

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(SUZY) A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

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A client who abuses marijuana reports liking the drug for its perceived effects. Which reported experiences should a nurse attribute to marijuana use? SELECT ALL THAT APPLY! 1) Sexual Intensity 2) Racing Heartbeat 3) Energy 4) Euphoria 5) Appetite Suppression 6) Fine Muscle Coordination

1) Sexual Intensity 2) Racing Heartbeat 4) Euphoria

An adult client diagnosed with obsessive-compulsive personality disorder is being admitted into a psychiatric department after rubbing lesions into both hands and face from excessive washing. The client is refusing to accept any treatment for the wounds or for the mental health diagnosis. What actions should be taken by the nurse? SELECT ALL THAT APPLY. 1. Treat the clients injuries; the client is incompetent 2. Do not treat that client; the client is competent 3. Notify the client's physician of the refusal; the client is incompetent. 4. Notify the physician of the refusal; the client is competent. 5. Notify the client's family; the client is incompetent.

2. Do not treat that client; the client is competent 4. Notify the physician of the refusal; the client is competent.

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to believe the child is experiencing anxiety? 1. Not able to get comfortable. 2. Frequent requests for someone to stay in the room. 3. Inability to remember her exact address. 4. Verbalization of a feeling of tightness in her chest.

2. Frequent requests for someone to stay in the room.

The nurse evaluates a 3 year old with a developmental delay. Which assessment findings would suggest a diagnosis of autistic spectrum disorder? 1. The child does not enjoy playing frequently with the same toy. 2. The child is using echolalia. 3. The child goes to bed without a nighttime routine. 4. The child enjoys imaginative play.

2. The child is using echolalia.

A nurse is completing a health history on a client. Which information, obtained during the interview, should indicate to the nurse that the client has a substance dependence problem? SELECT ALL THAT APPLY. 1. Increased concern by family and friends regarding substance use. 2. The development of tolerance to increasing amounts of a substance. 3. The onset of withdrawal symptoms. 4. Continued occupational functioning in spite of increased use. 5. Unsuccessful efforts to reduce the amount of substance used. 6. Diminished social or recreational activities.

2. The development of tolerance to increasing amounts of a substance. 3. The onset of withdrawal symptoms. 5. Unsuccessful efforts to reduce the amount of substance used. 6. Diminished social or recreational activities.

A nurse is teaching a class to assistive personnel on depression. Which statement(s) by the nurse provide accurate informatino about depression? Select all that apply. 1. Depression is a condition in which behaviors can fluctuate between low mood and euphoria. 2. Women are approximately twice as likely as men to develop depression. 3. The rate of depression among adolescents increases with age. 4. Children in all age groups can become depressed. 5. Symptoms of perfectionism and rigid thought patterns are indicative of depression.

2. Women are approximately twice as likely as men to develop depression. 3. The rate of depression among adolescents increases with age. 4. Children in all age groups can become depressed.

A nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

2. Writing

A patient is being admitted to the psychiatric unit after a suicide attempt. The nurse plans to write a suicide prevention contract. To promote compliance and build a trusting relationship with the patient, the contract should 1. be written by the physician 2. be written jointly by the nurse and the patient 3. be written by a social worker 4. be written by the patient.

2. be written jointly by the nurse and the patient

The nurse knows that there are several symptoms of depressive illness. Which of the following is a clinical manifestation of Major Depressive Disorder (MDD)? 1. hypomanic episodes 2. insomnia 3. being lost in deep thought 4. complaints of blurred vision

2. insomnia

A client with chronic alcohol abuse has been admitted to a rehabilitation unit. The nurse knows that the client is denying alcoholism when he makes which of the following statements? 1. "My brother did this to me." 2. "Drinking always calms my nerves." 3. "I can stop drinking anytime I feel like it." 4. "Let's all plan to play cards tonight."

3. "I can stop drinking anytime I feel like it."

A client tells a nurse, "I usually have a few drinks when I get home from work, but always limit it to three. I'm not running the risk of becoming addicted, am I?" The nurse's best response is: 1. "As long as you don't have any social problems associated with your use of alcohol, you do not need to be concerned." 2. "If you are concerned, then you might be developing a dependency." 3. "Three drinks a day or a total of seven drinks in a week is considered high-risk drinking for women. You seem concerned that you might be developing an alcohol dependency." 4. "There is no harm in social drinking."

3. "Three drinks a day or a total of seven drinks in a week is considered high-risk drinking for women. You seem concerned that you might be developing an alcohol dependency."

A client is being discharged after a hospitalization for a suicide attempt. Which question asked but he nurse assesses the learned prevention and future coping strategies of the client? 1. "How did you try to kill yourself?" 2. "Do you have the phone number of the suicide prevention center?" 3. "What skills can you utilize if you experience problems again?" 4. " Why did you think life wasn't worth living?"

3. "What skills can you utilize if you experience problems again?"

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

*A depressed client tells a nurse, "Nothing gives me joy. Things seem hopeless." Which actions should by taken by the nurse when caring for this client? Prioritize the nurse's actions by placing each step in the correct order. ____ Demonstrate genuine empathy and caring in discussing client's feelings about suicide. ____ Evaluate the client's risk for suicide by direct questioning (asking about suicide intent and plan). ____ Initiate suicide precautions as needed, according to policy and standards of care. ____ Continue to support and monitor prescribed medical and psychosocial treatment plans. ____ Assist client in maintaining nutritional needs, hygiene, and grooming. ____ Contact the client's support system in collaboration with case manager and/or social services.

3____ Initiate suicide precautions as needed, according to policy and standards of care. 1____ Demonstrate genuine empathy and caring in discussing client's feelings about suicide. 2____ Evaluate the client's risk for suicide by direct questioning (asking about suicide intent and plan). 5____ Assist client in maintaining nutritional needs, hygiene, and grooming. 4____ Continue to support and monitor prescribed medical and psychosocial treatment plans. 6____ Contact the client's support system in collaboration with case manager and/or social services.

The nurse is assessing a 15-year-old girl who has been admitted for bulimia nervosa. Which clinical manifestation is the nurse most likely to find? 1) Coarse hair growth 2) Hypertension 3) Metabolic acidosis 4) Parotid gland tenderness

4) Parotid gland tenderness

After an RN has finished teaching the parents of an autistic child. The RN recognizes the need for additional teaching when the father states: 1. "We understand that we will have to work to provide behavior modification for the child." 2. " I realize that we will have to supervise the child continuously depending on the severity." 3. " We realize that we will need to try to maintain eye contact and be consistent in our approach." 4. " I realize that with the proper care and medication our child can be cured."

4. " I realize that with the proper care and medication our child can be cured."

A client recently diagnosed with depression tells a nurse that she is 2 months pregnant and is reluctant to take an antidepressant medication. The client asks what other treatment options are available. Which type of therapy should the nurse recommend as an alternate treatment for depression? 1. Client-centered therapy 2. Gestalt therapy 3. Therapeutic touch therapy 4. Cognitive behavioral therapy

4. Cognitive behavioral therapy

"An orthopedic client who broke his ankle while drinking at a party questions whether his drinking is "okay". He has never been arrested for driving intoxicated, nor has he experienced any health or relationship problems. He says he called in sick to work once after drinking and drove intoxicated several times. Family information validates his self-report. The nurse concludes the client has an alcohol abuse problem based on which characteristic of this syndrome?" 1. Drinking more than two drinks per occasion 2. The inability to stop drinking despite negative consequences. 3. Drinking that causes an individual to pass out or experience a blackout. 4. Drinking too much and too often with using poor judgement and having negative consequences.

4. Drinking too much and too often with using poor judgement and having negative consequences.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations

4. Hypertension, changes in level of consciousness, hallucinations

Which statement by a client being discharged from inpatient treatment for cocaine abuse would indicate an accurate understanding about the disease process of addiction? 1. "I'm really going to try to stay off the cocaine. I'm not worried about alcohol since I never had any problem with a glass or two of wine with dinner." 2. "Once my cravings go away I wont need to go to Narcotics Anonymous (NA) anymore. I'll be recovered." 3. "I feel so much better after talking to my therapist. I didn't realize I was hurting so much emotionally. I must have been using to deal with my emotional problems." 4. I didn't realize that staying off drugs meant changing my thoughts and emotions. I thought I could just learn to stop using cocaine. NA will help me make these changes."

4. I didn't realize that staying off drugs meant changing my thoughts and emotions. I thought I could just learn to stop using cocaine. NA will help me make these changes."

The nurse is preparing to care for a client with major depression. The priority nursing intervention is to assess the client's 1. response to medication administration 2. current mood and activity level 3. appetite and weight 4. risk of suicide

4. risk of suicide

A client diagnosed with persistent depressive disorder (dysthymia) is describing ongoing mood disturbances. Which would the nurse expect the client to state? 1.) "My anxiety seems to be getting worse by the day." 2.) "One minute I'm feeling sad, and the next I feel upbeat and happy." 3.) "I'm scared because the voices keep telling me to kill myself." 4.) "I'm feeling low, and the whole world looks pretty dismal all the time."

4.) "I'm feeling low, and the whole world looks pretty dismal all the time."

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A) Monitor vital signs B) Maintain NPO status C) Provide a safe environment D) Address hallucinations therapeutically E) Provide stimulation in the environment F) Provide reality orientation as appropriate

A) Monitor vital signs C) Provide a safe environment D) Address hallucinations therapeutically F) Provide reality orientation as appropriate

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? A) The adolescent gives away a DVD and a cherished autographed picture of a performer. B) The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. C) The adolescent becomes angry while speaking on the telephone and slams down the receiver. D) The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

A) The adolescent gives away a DVD and a cherished autographed picture of a performer.

(AMANDA) The nurse is completing her assessment on a 4-year-old child brought into the clinic by his concerned parents. While completing the assessment, the nurse notes which of the following as possible signs that the child is Autistic? (Select all that apply) A) The child has an abnormal aversion to touch, loud noises and light B) The child responds to communication by parroting the words just spoken by another C) The child starts to sing and dance to a familiar song that comes on the radio D) The child gets angry with his parents and cries when they take a toy from him that he is playing with E) The child is sitting very stiffly in his chair and engages in a rhythmic rocking behavior.

A) The child has an abnormal aversion to touch, loud noises and light B) The child responds to communication by parroting the words just spoken by another E) The child is sitting very stiffly in his chair and engages in a rhythmic rocking behavior.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. the client's speech pattern is rapid, and affect is belligerent. based on these observations, what is the nurse's immediate priority of care? A. Provide safety for the client and other clients on the unit. B. Provide the clients on the unit with a sense of comfort and safety. C. Assist the staff in caring for the client in a controlled environment. D. Offer the client a less stimulating area to calm down in and gain control

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

A 23-year-old male client is admitted to a psychiatric emergency unit after having been picked up by the police. He was walking around a residential neighborhood at night without shoes in the snow. The client appears confused and disoriented. What is the nursing action of highest priority? A.assess and stabilize his physical needs B. assess and stabilize his psychiatric needs C. arrange for admission to a medical unit D. attempt to contact a family member to obtain an accurate history

A.assess and stabilize his physical needs

A nurse is conducting a group session for children and adolescents who have been diagnosed with depression. Which behaviors would a nurse anticipate in this group? Select all that apply. A. Delusions B. Anxiety C. Mania D. Irritability E. Somatic symptoms, such as headache and stomachache F. Suicidal thoughts

B. Anxiety D. Irritability E. Somatic symptoms, such as headache and stomachache F. Suicidal thoughts

A patient tells the nurse that they have been feeling depressed almost everyday for the last 2.5 years. They state that they are still able to feel joy with certain activities, and they don't think their mood changes with the seasons. What mood disorder would the nurse think they have? A. Cyclothymia B. Dysthymia C. Melancholic depressive disorder D. Seasonal affective disorder

B. Dysthymia

A female client with Dissociative Identity Disorder (DID) who was just admitted with several burns on her wrists and ankles, and she is refusing to attend a support group. Which nursing diagnosis would have the highest priority? A: Self-care deficit B: Impaired sensory deficit C: Risk for self-mutilation D: Noncompliance

C: Risk for self-mutilation

When assessing a patient with severe depression, which of the following would the healthcare provider identify as a cognitive alteration? A) Powerlessness B) Low Self-Esteem C) Anxiety D) Somatic Delusions

D) Somatic Delusions

Analysis: A client was admitted to the inpatient unit 3 days ago with flat affect, psychomotor retardation, anorexia, hopelessness, and suicidal ideation. The physician prescribed 75 mg of venlafaxine extended release (an SSNRI) to be given every morning. The client interacted minimally with the staff and spend most of the day in his room. As the nurse enters the unit at the beginning of the evening shift, the client is smiling and cheerfully greets the nurse. He appears to be relaxed and joins the group for community meeting before supper. What should the nurse interpret as the most likely cause of the clients behavior? a. The venlafaxine is helping the clients symptoms of depression b. The clients sudden improvement calls for close observation c. The staff can decrease their observation of the client d. The client is nearing discharge due to the improvement of his symptoms

b. The clients sudden improvement calls for close observation

The nurse is planning an educational program for families of patients who have attempted suicide. The nurse should include which of the following statements in the teaching plan? Select all that apply. a) "Suicidal patients usually give many overt clues." b) "Suicidal patients will often completely isolate themselves immediately prior to the attempt." c) "Suicidal patients display subtle changes in behavior." d) "Suicidal patients do not generally display changes in behavior." e) "Suicidal patients may be noticed putting their affairs in order."

c) "Suicidal patients display subtle changes in behavior." e) "Suicidal patients may be noticed putting their affairs in order."

*A patient states: "I'm not worth anything. I have negative thoughts about myself. I want to go to sleep and never wake up." Which nursing intervention has the highest priority? a. self-esteem building activities b. anxiety self-control measures c. sleep enhancement activities d. suicide precautions

d. suicide precautions