mental health nclex study up

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 a helping one."

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

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

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. In fact, the client 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. Which is the appropriate nursing action?

Call the nursing supervisor.

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

A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply.

Irritability Hypertension Gastrointestinal disturbances

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason?

Protection from the risk of intimacy

A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which to assist the client in meeting nutritional needs?

Provide small, frequent meals.

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 is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?

Risk for aspiration

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 who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

Sit by client's bed holding his or her hand. Reminisce with the client and share a humorous story that the client enjoys. The nurse asks: "What can I do, that might make you feel more comfortable today?" The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

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?"

An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide?

"Discussing suicide with a client is not harmful."

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 would be therapeutic?

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

The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?

"I am the nurse and, as such, I'll have you know that all information is kept confidential."

The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?

"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

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."

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

"I hid my silverware from dinner last night." "I know that by this time tomorrow all my troubles will be over."

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

"I notice you are wearing a blue shirt." "Do you have any plans of harming yourself? "I will sit here with you even if you choose not to talk with me."

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 would be therapeutic?

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

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?

"What do you and your husband believe is the right thing for your children?"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?

"What do you find difficult about this situation?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?

"What is causing you to become agitated?"

The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

"What leads you to seek help now?"

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."

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply?

"Within a few hours"

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."

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."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?"

The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs should the nurse observe with tardive dyskinesia?

Abnormal movements and involuntary movements of the mouth, tongue, and face

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Alzheimer's disease

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

The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and terminal cancer

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon

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 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 student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply.

Autocratic leader Democratic leader Laissez-faire leader

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.

Avoidance Hyperarousal Reexperiencing

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder?

Body weight well below ideal range

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 for the registered nurse.

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.

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

The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention?

Contracts and immediate available crisis resources

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 defense mechanism?

Denial

The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply.

Denial Confabulation Perseveration Avoidance of questions

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

Misplacing a valuable object Difficulty coming up with the right word

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

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

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply.

Mutual learning Increased feedback Instilling a sense of belonging An opportunity to practice new skills in a relatively safe environment

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 primary health care provider immediately. Which nursing intervention is appropriate?

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

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

Open-ended questions and silence

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply.

Outlandish behaviors Purposeless arousal and movement Grandiose delusions of being King Arthur Incessant talking that includes sexual innuendos

The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.

Refer to hallucinations as if they are real. Ask the client directly about the hallucinations. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices.

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client.

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

Remain with the client at all times.

The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply.

Respond to stimuli Conduct electrical impulses Release chemicals called neurotransmitters

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 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 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 caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client?

Writing

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 client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?

Disulfiram

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply.

Effects on problem solving Effects on perceptual field Physical and other defining characteristics

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best?

Encourage the client to participate in a structured daily program of activities.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?

Examine and treat the wound sites.

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

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

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

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 (RN) and expects that the RN will take which action?

Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

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.

Hallucinations Delusions Neologisms

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

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

Hypertension, disorientation, hallucinations

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.

Looks at old snapshots of family Visits the spouse's grave once a month Visits the senior citizens' center once a month

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.

Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.

Medication management Monitoring and documenting behavioral changes Notifying the health care provider of behavioral changes Planning care for the needs of those clients with mental illness

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image. The client reports an extreme fear of public speaking. The nurse recognizes that this client is suffering from social phobia. Which are some other manifestations of social phobias? Select all that apply.

Performing badly on stage Looking awkward while eating or drinking in public Not being able to answer questions in a classroom Fear of saying something that sounds foolish in public

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 is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care?

Reward the client when a desired behavior is performed.

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

Risk for injury Risk for infection Risk for aspiration Impaired verbal communication

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need?

Safety and security

The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply.

Set limits on behavior. Distract or redirect the client. Decrease environmental stimulation. Provide high caloric nutritional intake.

The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client?

Shift the focus from the client's somatic concerns to feelings and coping skills.

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.

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

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

The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.

Diaphoretic Temperature of 104.8° F Blood pressure of 210/130 mm Hg

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?

Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

Stay with the client. Administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli.

The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?

Suggest that the client stop talking and try listening to others.

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment?

Suggest that the mother's boyfriend move out of the home.

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

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 is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event?

The death of a loved one

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

The presence of existing suicidal thoughts

The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder?

light therapy