MH FINAL NCLEX

During a mental status examination, the nurse assesses a client's level of consciousness. Appropriate responses the nurse would explore include: A. Recent and remote memory B. Mood and emotional state C. Alertness and ability to respond D. Articulation and rate of speech

C. Alertness and ability to respond

A nurse is discussing confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? A. "The courts may require me to discuss confidential information" B. "I am required to provide confidence info to insurance companies" C. "If questioned during a police investigation I am required to divulge confidential information" D. "I am legally allowed to discuss confidential information to the client's former therapist"

A. "The courts may require me to discuss confidential information"

A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has legal right to refuse treatment? A. A 16-year-old client whose parents have requested treatment B. An adult client who has delusions and refuses treatment for religious reasons C. An older adult client who was voluntarily admitted D. A client who is competent but was involuntarily admitted

C. An older adult client who was voluntarily admitted

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states "I'm feeling sad, I don't want to talk now." Which of the following is an appropriate response? A. It will help you feel better if you talk about it B. I'll come back when you feel like talking C. I'll stay with you a few minutes D. Sometimes it helps to talk

C. I'll stay with you a few minutes

The nurse asked the client the following what does this mean don't cry over spilled milk what is the nurse assessing A.) memory B.) recall C.) concrete thoughts D.) comprehension

C.) concrete thoughts

The nurse observes a client who is fidgeting ringing their hands in his body tenses and a wrinkle brow what's the best response to the client by the nurse? A.) you look tense can you tell me if something is making you afraid or nervous B.) you look upset would you like some medication to help you become more calm C.) you look worried is something bothering you D.) why are you so nervous and jumpy

A.) you look tense can you tell me if something is making you afraid or nervous

A nurse is caring for a client who begins to make sexual advances towards the nurse. Which of the following is an appropriate statement by the nurse? A. "I am going to leave now and I'll return in one hour to spend time with you then" B. "I'm sure that you don't intend to behave this way so I'm going to ignore this behavior" C. "I'm very flattered but I am married and cannot engage in this behavior" D. "I'm curious as to why you are behaving this way. Can you please explain it to me?"

A. "I am going to leave now and I'll return in one hour to spend time with you then"

In the development of a therapeutic relationship with a new admission with the dx of post self-inflicted GSW to the head. Which of the following is a priority for the nurse? A. Assess your feelings toward this client B. Assess the client's level of suicidality C. Assess the client's support systems D. Assess the client's plan for suicide

A. Assess your feelings toward this client

A nurse in a psych unit is caring for a client who is being admitted involuntarily after attacking a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over if the client A. Is a danger to herself or others B. Is unwilling to accept that treatment is needed C. Does not have anyone that she could stay with D. Is financially incapable of pay8ing for prescribed medication

A. Is a danger to herself or others

In an individual therapy session, a client freely expresses his fears to the nurse. Which response by the nurse would be considered nontherapeutic? A. The nurse states, "I'm sure everything will turn out fine" B. The nurse asks, "Are you worried about how long you will be in therapy?" C. The nurse leans toward the client and gently D. The nurse positions herself on the client's level and makes eye contact

A. The nurse states, "I'm sure everything will turn out fine"

The RN must inform a family member his mother did that just died when informed of this news the 35 your own Sasan smile's estate he is going to the vending area to buy candy what is the most appropriate intervention for the nurse to make it this time? A.) Allow him to go and sort out his feelings b.) repeat I just told you your mother died how did you feel about this? C.) have the healthcare provider meet with the son D.) ask him if you like time alone with his mother

A.) Allow him to go and sort out his feelings

In the two months following his wife's death Mr. Smith age 84 and in good physical health as you going to pay less attention to his hygiene and says he feels useless since he does not have his wife to care for he complains of difficulty concentrating and sleeping and says that he lacks energy his family sometimes has to remind him to shower take his medication all of which he did then does on his own which response is most appropriate? A.) Arrange for an appointment for evaluation and treatment of suspected depression b.) re-orient Mr. Smith by pointing out the day and date each time that you interact with him c.) meet with family and support person's to help them except for dissipate and prepare for progression of his stage III dementia D.) avoid touch and proximity these are likely to be uncomfortable for Mr. Smith and may progress provoke aggressing and this oriented

A.) Arrange for an appointment for evaluation and treatment of suspected depression

The nurse is conducting a daily nursing assessment on a client with gambling and alcohol addictions who is in the outpatient addiction program which client statement reflects a need for more teaching A.) I am going to have a night out with some friends add an area nightclub b.) I felt like drinking so I clean the house instead c.) it is hard for me to make phone calls I feel like going out I did last night d.) I told my brother that I couldn't help him as much as I have in the past

A.) I am going to have a night out with some friends add an area nightclub

The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority? A.) Its important to limit your driving to short periods. Sleep deprviation increases your risks for serious accidents. B.) Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year. C.) Turn the radio on with a soft volume as you prepare for bed each evening. It will help you relax. d.) Three glasses of wine each evening help many patients who suffer from sleep deprivation.

A.) Its important to limit your driving to short periods. Sleep deprviation increases your risks for serious accidents

In the development of a therapeutic relationship with a new admission with the diagnosis of post self-inflicted gunshot wound to the head which of the following is the priority for the nurse? A.) assess your feelings towards the client b.) assess the clients level of suicidality c.) assess the client support system D.) assess the clients plan for suicide

A.) assess your feelings towards the client

An older adult is prescribe digoxin and Hydro chloro thiazide daily as well as lorazepam 2 mg PO as needed for anxiety the patient has had three doses of Ativan over two days in addition to routine medications the patient developed confusion slurred speech unsteady gait and fluctuating levels of orientation what is the most likely reason for the patients change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A. Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem

A 21-year-old male college student who has become increasingly suspicious of others has accused a professor of conspiring with two other classmates to get him expelled from school. The client is admitted to a psychiatric unit after telephoning and threatening to kill the professor and his classmates. The client states, "They are all out to get me expelled. I think they are trying to kill me. I have to stop them." What would be a therapeutic appropriate response by the nurse? A."Why do you think they are out to get you expelled or to kill you?" B. "It is difficult to believe that your professor and classmates are out to get you expelled or to kill you" C. "It's not right to kill others even if they are out to get you expelled or want to kill you" D. "Your professor and classmates are not out to get you expelled or to kill you. Let's look at the facts"

B. "It is difficult to believe that your professor and classmates are out to get you expelled or to kill you"

A terminal cancer client states to the nurse, "I wish my family would stop hoping for a cure. I know I am going to die and I wish they would stop." The nurse's best response is... A. "We can't control our family's feelings" B. "It sounds as though you are feeling angry your family is still hoping for a cure" C. "I can tell you are in acceptance" D. "I will tell the team to arrange a family meeting"

B. "It sounds as though you are feeling angry your family is still hoping for a cure"

A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at appropriate times when at home. Which of the following instructions is appropriate? A. "You really shouldn't change the schedule we established here in the hospital" B. "Let's work together to devise a time schedule that is convenient for you on a daily basis" C. "We'll have to talk to your doctor about switching to an alternative schedule" D. It doesn't really matter what time you take your medication as long as you don't skip any doses"

B. "Let's work together to devise a time schedule that is convenient for you on a daily basis"

A client hears voices telling him that he is a terrible person who would be better off dead. What would be a priority nursing diagnosis for the nurse to select for the patient? Which of the folliwng approaches would be the best for the nurse who is communicating with the cognitively impaired client? Select all that apply. A. Loud B. Concise C. Clear D. Nonverbal E. Unhurried

B. Concise C. Clear E. Unhurried

The nurse concludes that which living environment would be the safest for a client who inflicted harm on a family member earlier in the day? Select all that apply. A. In a local respite home B. In a locked unit C. In an open-door seclusion room D. In a close-door seclusion room E. With a family member in another state

B. In a locked unit D. In a close-door seclusion room

The nurse would conclude that a client with schizophrenia is exhibiting positive symptoms of the disorder after noting that the client does which of the following? Select all that apply. A. Exhibits lack of energy B. States that he is a king C. Repeats words the nurse says D. Has a flat affect E. Withdraws from other people

B. States that he is a king C. Repeats words the nurse says

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 secondary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effect of depression D. Providing support groups for clients at risk for depression

B. Performing screenings for depression at community health programs

A sixteen-year-old Asian client requests an outside provider give her a coining treatment. What is the RN's best response? A. Respect cultural beliefs and allow the treatment B. Respect cultural beliefs, but do not allow the treatment in the hospital C. Educate the family on Western medicine D. Encourage the client to try accepted practices

B. Respect cultural beliefs, but do not allow the treatment in the hospital

A fellow nurse reports a strange experience she was riding with her carpool partner after working her second double shift in a row when she looked down at her hands on her lap and did not immediately recognize them as her own they seem small and far away to her she felt like I wasn't myself for several minutes after which the gradually return to normal this happened several weeks ago and she has never had a similar experience since then and has continued to work she is worried that this is not normal and ask you about it which response most accurately reflects what different probably experienced A.) Not excepting part of one's body as one's own is an indication of body dysmorphic disorder or this is a psychiatric disorder and prompt treatment is needed B.) The long hours of work with little recovery time led her to have a transient episode of the personalization these are Common stress related and not a sign of major illness C.) The friend had a mini fugue experience which suggest deeper underlying conflicts or past trauma that has not resolved it could progress and marriage counseling D.) Such feelings of unreality could be early symptoms of dissociative identity disorder or she might not have recognize her own body because after personality was taking control

B.) The long hours of work with little recovery time led her to have a transient episode of the personalization these are Common stress related and not a sign of major illness

What is a good lunch for a manic client? A.) Ribs with mashed potato B.) peanut butter sandwich and a carton of milk C.) pizza cake and ice cream d.) cheeseburger and fries

B.) peanut butter sandwich and a carton of milk

A client on the psychiatric unit states, "I feel like a bird". The best response for the nurse to make is... A. "You are a patient not a bird" B. "Birds can fly, can you?" C. "That must be distressing for you, you don't look different to me" D. "What you say indicates to me the reason you are in this hospital"

C. "That must be distressing for you, you don't look different to me"

A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. A. "Don't talk that way. Of course you will leave here!" B. "Keep up the good work, and you certainly will" C. "You don't think you're making progress?" D. "Everyone feels that way sometimes"

C. "You don't think you're making progress?"

A client living in an assisted living facility is taking conventional antipsychotic medications. One evening the nurse notices that the client is experiencing muscle rigidity, confusion, delirium, and has a temperature of 104 degrees Fahrenheit. The nurse interprets these symptoms of which adverse drug effects? A. Dystonia B. Akathisia C. Neuroleptic malignant syndrome D. Tardive dyskinesia

C. Neuroleptic malignant syndrome

A nurse who is not religious is caring for a client who is Catholic and is dying. The client requires a baptism, but no ministers are immediately available. After assessing that death is imminent, the nurse should A. Obtain water so that the client may perform the baptism B. Call for a nurse who is catholic to baptize the client C. Perform the baptism D. Inform the client that a desire for a baptism can be substituted for the action of baptism

C. Perform the baptism

A home health care nurse is visiting an older client who tells the nurse that she is feeling tired and is unable to shop for groceries. The client asks the nurse is she could pick up a few things for her at a local store. Which of the following is an appropriate nursing response? A. "It is against policy for me to grocery shop for you" B. "I would be happy to do whatever I can to help you" C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then" D. "It's unfortunate that you don't have someone to help you on the days you don't feel well. Let's talk about how we can solve this for you"

D. "It's unfortunate that you don't have someone to help you on the days you don't feel well. Let's talk about how we can solve this for you"

A client states that he is able to receive radio waves from aliens because they places a computer chip in his brain. The nurse would document this behavior as which of the following in the medical record? A. A hallucination B. Reality-oriented C. An illusion D. A delusion

D. A delusion

A 15-year-old female client refuses to participate in scheduled activities on the adolescent mental health unit. She pushes another client, causing her to fall. Which approach by the nursing staff would be most therapeutic? A. Permit the client to refuse participation B. Coax the client to gain compliance C. Offer the client rewards in advance D. Establish firm limits with the client

D. Establish firm limits with the client

What would be the best approach for a nurse to use to encourage the client with psychological distress to develop an awareness of feelings and express them effectively? A. Challenge the client B. Offer reassurance C. Suggest coping strategies D. Offer empathy

D. Offer empathy

A nurse is providing psychotherapy to a client who is having difficulty recognizing her problems. Which quality must the nurse possess to be most therapeutic with this client? A. Values B. Sympathy C. Understanding D. Self-awareness

D. Self-awareness

What activity is most appropriate for a bipolar client? A.) a game of twister B.) a football game with other clients C.) riDing on the stationary bike D.) coloring activity with the nurse

D.) coloring activity with the nurse

A 15-year-old female client refuses to participate in scheduled activities on the adolescent mental health Unit she pushes another client causing her to fall which approach by the nursing staff would be most therapeutic? A.) permit the client to refuse participation B.) coax the client to gain compliance C.) offer the client rewards in advance D.) established firm limits with the client

D.) established firm limits with the client

Which statement shows the nurse has empathy for a patient who made a suicide attempt? a.) you must have been very upset when you try to hurt yourself b.) it makes me sad to see you going through such a difficult experience c.) if you tell me what is troubling you I can help you solve your problems d.) suicide is a drastic solution to a problem that may be such a serious matter

a.) you must have been very upset when you try to hurt yourself

A client is scheduled for ECT. What family teaching should the RN focus on? a. education on the importance of airway maintenance. b. education on the client's memory loss c. education on the use of brevital as a anesthesia d. education on the purpose of ECT

b. education on the client's memory loss

The nurse instruct the client about addiction the nurse determines that the client understands the information given when the client makes which statement select all that apply a.) addiction is a moral problem b.) addiction is a medical illness c.) addiction is a behavioral habit d.) addiction is a emotional attachment e.) addiction is difficult to cure

b.) addiction is a medical illness c.) addiction is a behavioral habit d.) addiction is a emotional attachment

Which client is at risk for committing suicide? a.) mother whose son just died b.) elderly single male with CA c.) teenager who broke up with his girlfriend d.) Married businessman with alcoholism

b.) elderly single male with CA

A client is diagnosed with major depression what is the most important part of the mental status exam to assess? a.) judgment b.) mood c.) insight d.) behavior

b.) mood

In a sad voice in elderly patient tells the nurse of the recent death of a spouse and daughter in an automobile accident as the patient sadly relates that she has no other family only a few acquaintances in the community she says there is no hope the nurses priority is to gather additional assessment data to determine which nursing diagnosis best direct care for this patient? a.) Spiritual distress related to being angry with God for taking her family so abruptly b.) risk for suicide related to hopelessness after recent deaths of significant others c.) anxiety related to sudden and abrupt lifestyle changes d.) social isolation related to loss of existing's family support systems

b.) risk for suicide related to hopelessness after recent deaths of significant others

A nurse has observed that the client is still crying often expresses anger at her decreased deceased husband after nine months and has stop seeing friends and family she is complaining that she is feeling hopeless to change anything to improve her future the priority assessment would be: a.) no assessments needed this is within the normal time axtent of grieving b.) symptoms of complicated grief dysfunctional morning and social isolation c.) social support and family systems d.) symptoms of anxiety and isolation

b.) symptoms of complicated grief dysfunctional morning and social isolation

The nurse is deciding if she can restrain and angry acting out client the client told her I will sue you if you Tie me down her best response would be : A.) if you cannot be kept from hurting yourself or others I will need to restrain you. b.) you have a right to remain silent because anything you say will be used to determine your need for a strain c.) your lawyer would not take the case because we have done everything right and what the document carefully D.) no one has access to our confidential records so you have no verifiable basis for a lawsuit

b.) you have a right to remain silent because anything you say will be used to determine your need for a strain

The mental health nurse explains the clients who are learning about cross addiction that there is a synergetic or addictive affect from various kinds of chemicals together the nurse illustrates this point using which example of items that create the combined additive effects a.) drinking beer and smoking cigarettes b.) drinking coffee and eating donuts c.) drinking wine and taking a benzodiazepine d.) drinking wine and coffee

c.) drinking wine and taking a benzodiazepine

A 20-year-old economics major became severely depressed after failing to exams in economics she cried for two hours and then call her parents who live in neighboring state planning to ask if she could return home however her parents were in Europe when her roommates went home for the weekend the patient gave her three expensive sweaters to keep later the dormitory resident assistant return a book to the patient's room and found her unconscious on the floor with an empty pill bottle nearby the patient behavior has provided a clue to the suicide attempt was: a.) calling her parents b.) staying in her dorm room c.) giving away her favorite possessions d.) excessive crying

c.) giving away her favorite possessions

A male client is coming down from a manic. He states I feel bad about cheating on my wife what is the nurse best response? A.) You can't help it it's part of your illness b.) let's discuss your feelings with your wife c.) hypersexuality is part of your illness let's discuss early signs of a manic episode d.) you better be or your wife will divorce you

c.) hypersexuality is part of your illness let's discuss early signs of a manic episode

Randall is a 36-year-old male admitted to the hospital for symptoms of depression and passive suicidal thoughts he tells the nurse a potted mission I know I need to be here and I'm happy you were going to be my nurse when I'm here you are such a good listener for the remainder of the shift Randall ask the nurse for numerous one to one conversations and make several comments about how much he likes her in this situation the nurses best response to the patient's behavior would be to: a.) spend as much time as possible with the patient to allow him to feel comfortable on the unit b.) immediately report to the treatment team the patients inappropriate comments c.) set limits on interactions with this patient and discussed his case with Fellow nurses and supervisors d.) offer medications to help the patient deal with this anxiety

c.) set limits on interactions with this patient and discussed his case with Fellow nurses and supervisors

During a meeting on an inpatient addictions unit a newly admitted client asks what defines drug abuse the best response by the nurse is that drug abuse is A.)a physiological need for a drug b.) a physiological dependence on a drug c.) a compulsion to take a drug on either a continual or periodic basis d.) an excessive drug use inconsistent with excepted medical purposes

d.) an excessive drug use inconsistent with excepted medical purposes