NCLEX Mental Health

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority? 1.Fear 2.Anxiety 3.Risk for aspiration 4.Altered health maintenance

3.Risk for aspiration

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? 1."Discussing suicide with a client is not harmful." 2."Those clients who talk about suicide never do it." 3."Depressed clients are the only people who commit suicide." 4."When a person talks about making suicide threats, the person is seeking attention.

1."Discussing suicide with a client is not harmful."

The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply. 1.Mild 2.Panic 3.Severe 4.Rational 5.Moderate 6.Hallucinatory

1.Mild 2.Panic 3.Severe 5.Moderate

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. 1.Monitor vital signs. 2.Maintain an NPO status. 3.Provide a safe environment. 4.Address hallucinations therapeutically. 5.Provide stimulation in the environment. 6.Provide reality orientation as appropriate.

1.Monitor vital signs. 3.Provide a safe environment. 4.Address hallucinations therapeutically. 6.Provide reality orientation as appropriate.

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings? 1.Use open-ended questions and silence. 2.Focus on the components of adequate nutrition. 3.Focus on the fact that the client's beliefs are untrue. 4.Instruct the client about the need for adequate nutrition.

1.Use open-ended questions and silence.

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time? 1."No, we can't talk right now; it is bedtime." 2."I can see that you're upset. I'm willing to listen." 3."Try to get some sleep, and we will talk in the morning." 4."I don't have time right now, but I'll get someone else to talk to you."

2."I can see that you're upset. I'm willing to listen."

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response? 1."You're not a loser—you are just sick right now." 2."You don't think you can ever do anything right?" 3."Everything will get better—just you wait and see." 4."What makes you think you can't do anything right?"

2."You don't think you can ever do anything right?"

The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client? 1."It is very, very hard to get over these types of feelings after being raped." 2."What do you think you need to do to reduce the likelihood that you will be raped again?" 3."Tell me more about what happened that causes you to feel like the rape just occurred." 4."It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

3."Tell me more about what happened that causes you to feel like the rape just occurred."

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? 1."With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

3."What leads you to seek help now?"

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply. 1.Male gender 2.Caucasian race 3.Age less than 32 years 4.Practicing a religion 5.Married over 10 years

3.Age less than 32 years 4.Practicing a religion 5.Married over 10 years

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1.Plan short-term goals. 2.Identify expected outcomes. 3.Assist with making appropriate referrals. 4.Assist with developing realistic solutions.

3.Assist with making appropriate referrals.

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply. 1.Effects on environment 2.Dysfunctional behavior 3.Effects on problem solving 4.Effects on perceptual field 5.Healthy reaction necessary for survival 6.Physical and other defining characteristics

3.Effects on problem solving 4.Effects on perceptual field 6.Physical and other defining characteristics

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. 1.Incontinence of stool 2.Confusion as to day and time 3.Misplacing a valuable object 4.Forgetfulness of recent events 5.Difficulty coming up with the right word

3.Misplacing a valuable object 4.Forgetfulness of recent events 5.Difficulty coming up with the right word

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? 1.Self-esteem 2.Physiological care 3.Safety and security 4.Love and belonging

3.Safety and security

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1."My medications won't make me anxious." 2."I'll go to a support group and talk so that I won't hurt anyone." 3."I won't get anxious or hear things if I get enough sleep and eat well." 4."I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

4."I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective? 1."I'll eat until I don't feel hungry." 2."I no longer have a weight problem." 3."I don't want to starve myself anymore." 4."My friends and I went out to lunch today."

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

The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client? 1.Ping-pong 2.A paint-by-number activity 3.A brown bag lunch and a book review 4.A deep breathing and progressive relaxation group

1.Ping-pong

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply. 1.Provide high-calorie finger foods. 2.Decrease the light and noise level on the unit. 3.Restrict the client's access to money and other valuables. 4.Encourage the client to play volleyball with other clients on the unit. 5.Avoid rest periods during the day to ensure for adequate rest at night.

1.Provide high-calorie finger foods. 2.Decrease the light and noise level on the unit. 3.Restrict the client's access to money and other valuables.

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? 1.Clonidine 2.Disulfiram 3.Pyridoxine 4.Chlordiazepoxide

2.Disulfiram

. A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurses most important aspect of care is to maintain client safety and plans to 1.Request that a peer remain with the client at all times. 2.Remove the client's clothing and place the client in a hospital gown. 3.Assign a staff member to the client who will remain with him or her at all times. 4.Admit the client to a seclusion room where all potentially dangerous articles are removed.

3.Assign a staff member to the client who will remain with him or her at all times.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1.Engaging in immoral acts 2.Always reinforcing self-approval 3.Observing rigid rules and regulations 4.Having the need to always make the right decision

3.Observing rigid rules and regulations

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which? 1.More than one assault 2.Refusing to admit the rape-trauma episode 3.Reexperiencing recollections of the trauma 4.Imagining the use of force in a sexual situation

3.Reexperiencing recollections of the trauma

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? 1."I know just how you feel because I lost my husband last summer." 2."It's okay to grieve and be angry with your daughter and anyone else for a time." 3."You need to focus on the many good years you both enjoyed together and move on." 4."Although it's a troubling time for you, try to focus on your children and grandchildren."

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

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1.Plan nothing until the client asks to participate in the milieu. 2.Encourage the client to participate in a structured daily program of activities. 3.Give the client a menu of daily activities and insist that the client participate in all activities offered. 4.Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.

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

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply. 1.Selective inattention 2.Oblivious to surroundings 3.Unable to focus on anything 4.Engaging in purposeless activity (walking around aimlessly) 5.Physical behavior may become erratic, uncoordinated, and impulsive. 6.Showing unproductive relief behavior (stomping, wringing hands, dropping things)

2.Oblivious to surroundings 3.Unable to focus on anything 4.Engaging in purposeless activity (walking around aimlessly) 6.Showing unproductive relief behavior (stomping, wringing hands, dropping things)

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic? 1."Have you told your family how you feel?" 2."They are right. You shouldn't be so worried." 3."You certainly have enough to worry about right now." 4."You're feeling angry that your family is hoping for a cure?"

4."You're feeling angry that your family is hoping for a cure?

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? 1.Reality therapy 2.Psychodrama 3.Psychoanalytical therapy 4.Short-term psychotherapy

2.Psychodrama

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? 1.Identifying the client's ability to function 2.Identifying the client's potential for self-harm 3.Inquiring about the client's feelings that may affect coping 4.Inquiring about the client's perception of the cause of the neighbor's death

3.Inquiring about the client's feelings that may affect coping

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? 1.Avoid providing rewards to the client. 2.Promote complete independence in the client. 3.Reward the client when a desired behavior is performed. 4.Provide consistent negative reinforcement to promote appropriate behaviors.

3.Reward the client when a desired behavior is performed.

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client? 1."Go on...." 2."Sleeping?" 3."The last couple of nights?" 4."Tell me about your difficulty sleeping."

4."Tell me about your difficulty sleeping."

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? 1."Right! Why not just 'pack it in'?" 2."That seems rather unlikely to me." 3."I don't believe that, and neither do you." 4."You must be feeling all alone at this point."

4."You must be feeling all alone at this point."

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1.Tell the client that this is not true and that we all have a purpose in life. 2.Remain with the client and sit in silence until the client verbalizes feelings. 3.Identify recent behaviors or accomplishments that demonstrate skill or ability. 4.Reassure the client that you know how the client is feeling and that things will get better.

3.Identify recent behaviors or accomplishments that demonstrate skill or ability.

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first? 1.Restrain the client. 2.Fill out an incident report. 3.Remove both clients to a separate, safe location. 4.Call the hospital risk management department.

3.Remove both clients to a separate, safe location.

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? 1.Dental erosion 2.Electrolyte imbalances 3.Enlarged parotid glands 4.Body weight well below ideal range

4.Body weight well below ideal range

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? 1.The past treatment regimen 2.Food intake for the past 24 hours 3.The client's interaction with peers 4.The presence of existing suicidal thoughts

4.The presence of existing suicidal thoughts

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? 1."When children are hurt the way you hurt them, people want you isolated." 2."You're lucky it doesn't escalate into something pretty scary after your crime." 3."You understand that people fear for their children, but you're feeling unfairly treated?" 4."You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

3."You understand that people fear for their children, but you're feeling unfairly treated?"

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? 1.Request that a peer remain with the client at all times. 2.Remove the client's clothing and place the client in a hospital gown. 3.Assign a staff member to the client who will remain with him or her at all times. 4.Admit the client to a seclusion room where all potentially dangerous articles are removed.

1.Request that a peer remain with the client at all times. 2.Remove the client's clothing and place the client in a hospital gown. 3.Assign a staff member to the client who will remain with him or her at all times. 4.Admit the client to a seclusion room where all potentially dangerous articles are removed.