NCLEX - Mental Health
The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval
1,2,4,5.
Which are characteristics of the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with each other. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.
1,2,6.
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 would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."
2,3,5.
The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment
2,3,5.
A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis
2.
A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid though process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Though broadcasting or delusions
2.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge
2.
The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the most appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "It depends on what the secret is about." 4. "If you tell me the secret, I may need to document it."
2.
A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies
3,5.
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.
The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development? 1. Acknowledging that the group has identified goals 2. Encouraging the accomplishment of the group's work 3. Acknowledging the contributions of each group member 4. Encouraging members to become acquainted with one another
3.
Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client." 2. "A client's rights are guaranteed by both state and federal laws." 3. "Being respectful and concerned will ensure that I'm attentive to my client's rights." 4. "Regardless of the client's condition, all nurses have the duty to respect client rights."
3.
A client is admitted to the mental health unit 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
4.
A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"
4.
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function tests 4. White blood cell count
4.
A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination
4.
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping
4.
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs
4.