MH NCLEX Practice Questions

The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

2. Examine and treat the wound sites. Assess, treat first

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? SATA a. Initiate confinement measures b. Acknowledge the clients behavior c. Assist the client to an area that is quiet d. Maintain a safe distance from the client e. Allow the client to take control of the situation

B, C, D Escalation period - client's behavior is moving to loss of control

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

c. What leads you to seek help now? Asking this helps the nurse determine what led to the event and define the problem more clearly. A, B assess situation D client is not ready to learn coping skills

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? a. You need to stop that behavior now b. You will need to be placed in seclusion c. You seem restless; tell me what is happening d. You will need to be restrained if you do not change your behavior

c. You seem restless; tell me what is happening This question helps the client be aware of the behavior and help the nurse plan interventions

The nurse is creating a plan of care for a client in crisis state. When developing the plan, the nurse should consider which factor? a. A crisis state indicates that the client has a mental illness b. A crisis state indicates that the client has an emotional illness c. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis d. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

d. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting the crisis is over. The client says to the nurse. "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? a. Suggesting a reduction of medication b. Allowing increased "in-room" activities c. Increasing the level of suicide precautions d. Allowing the client off-unit privileges as needed

c. Increasing the level of suicide precautions When a client in care for a short time drastically improves, it is likely they have made the decision for self harm.

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? a. Have you talked to your family about this? b. Everyone feels this way when they are depressed c. You will feel better once your medication begins to work d. You sound very upset. Are you thinking of hurting yourself?

d. You sound very upset. Are you thinking of hurting yourself? Suicide risk

The ER nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? a. Information regarding shelters b. Instructions regarding calling the police c. Instructions regarding self-defense classes d. Explaining the importance of leaving the violent situation

a. Information regarding shelters Tertiary prevention

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? a. One-to-one suicide precautions b. Suicide precautions with 30-minute checks c. Checking the whereabouts of the client every 15 minutes d. Asking the client to report suicidal thought immediately

a. One-to-one suicide precautions

The nurse in the ER is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused and at times physically immobile. How should the nurse interpret these behaviors? a. Signs of depression b. Reactions to a devastating event c. Evidence that the client is a high suicide risk d. Indicative of the need for hospital admission

b. Reactions to a devastating event Acute phase - wide range of emotion and somatic response

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

b. The death of a loved one Situational - external sources: change job, loss loved one, abortion, divorce, addition new family members, pregnancy, illness A, C and D adventitious: natural disaster, national disaster, crime, violence

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure patient safety by which action? a. Requesting that a peer remain with the client at all times b. Removing the client's clothing and placing them in a hospital gown c. Assigning to the client a staff member who will remain with client at all times d. Admitting the client to a seclusion room where all potentially dangerous articles are removed

c. Assigning to the client a staff member who will remain with client at all times Safety

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? SATA a. I'm afraid of spiders b. I keep reliving the robbery c. I see his face everywhere I go d. I don't want anything to eat now e. I might have died over a few dollars in my pocket f. I have to wash my hands over and over many times.

B, C, E

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 cherished autographed picture of a performer b. The adolescent runs out of the therapy group swearing at the group leader, and 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 cherished autographed picture of a performer This is a sign of suicide and way of saying goodbye B, C, D are anger issues and typical of adolescents

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? a. You need to try to be realistic. The rape did not just occur b. It will take you some time to get over these feelings about your rape c. Tell me more about the incident that causes you to feel like the rape just occurred d. What do you think you can do to alleviate some of your fears about being raped again?

c. Tell me more about the incident that causes you to feel like the rape just occurred Client needs to be reassured feelings are normal and gives a safe place to express them