NCLEX Psych

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

"Tell me about your difficulty sleeping"

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

- "My husband always brings me flowers & apologizes after he hits me." - "My boyfriend yells & accuses me of having an affair if I am late after work." - "I have bruises all over my body. I am frequently clumsy & fall a lot."

On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe?

A fear of leaving the house

Stress is:

A response to any demand made upon the individual

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 analyzes this information & determines that the client's fear would be considered which diagnosis?

A social phobia

Anxiety is possible to define as:

A vague feeling of apprehension

A client has just been admitted to the mental health unit with a diagnosis of OCD. The nurse observes the client for compulsive behavior that denotes repetition in which?

Actions

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

Agoraphobia

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 about hurting yourself?"

A nursing assistant is assigned to work with a nurse to care for a client who was at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide?

"Discussing suicide with a client is not harmful."

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation & urinary retention, knowing that these problems are likely caused by which?

Psychomotor retardation & side effects of medication

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

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 & anxiety & determines that the client understands the interventions when the client states which?

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

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse should make which appropriate response?

"It sounds as though you are feeling all alone right now."

A client is admitted to the in-patient unit & is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant & anxious. The client's mother begins to cry & states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together & discuss any concerns you may have?"

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, & 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 should be therapeutic?

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

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 nursing response is appropriate?

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

A client who is experiencing suicidal thoughts states to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" The appropriate initial nursing response is:

"What do you mean by that?"

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

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

A 75-year-old male with severe depression & cancer

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

A 90 yo woman with Parkinson's disease

A client is scheduled to have electroconvulsive therapy (ECT). The nurse tells the client that:

Amnesia of events occurring near the period of the therapy is common.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and do which?

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

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks & boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning phase

The nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. Which finding requires the nurse's immediate intervention?

Client's inadequate attention to ADLs & poor nutritional intake

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder & mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?

Constant physical activity & poor oral intake

Which data indicates to the nurse that a client may be experiencing ineffective coping following the loss of her spouse?

Constantly neglects personal grooming

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

Contracts & immediately available crisis resources

A client was admitted to a medical unit with acute blindness. Many tests are performed & there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-&-run car crash, in which a family of 3 was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder

In the 20th century, changes in the delivery of mental health care resulting from the development of electroconvulsive therapy & psychotherapeutic drugs brought about the phenomenon of:

Deinstitutionalization

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 (Antabuse)

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

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

Examine & treat the wound sites

A client has been brought to the ER after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area & assess the airway

When caring for a client who has been raped, which intervention would the nurse implement during the examination?

Explaining procedures to be completed & why the procedures are necessary

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

HTN, disorientation, hallucinations

A 14 yo is having a difficult adolescence. Over the summer, she grew 3 in & developed large breasts. 1 day, after boys teased her & imitated her figure, she went to the school nurse crying. What's the 1sst step for the nurse to take?

Have her tell in detail what happened

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

Have the client open the gift with the nurse present

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling & reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:

Increasing the level of suicide precautions

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.

The nurse is preparing to admit a client diagnosed with OCD to the mental health unit. The nurse should observe this client for which behavioral characteristic(s)?

Inflexible & rigid

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, the nurse should:

Inform the client that she is being secluded to help regain control of self

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

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

Reported hopelessness

Defense mechanisms are:

Means of managing conflict

A nurse in the ER is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, & physical evidence has been collected. The nurse notes that the client is withdrawn, confused, & at times physically immobile. These behaviors are interpreted by the nurse as:

Normal reactions to a devastating event

The nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of which condition?

PTSD

The highest priority in crisis intervention is:

Patient safety

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, & using aggressive gestures & rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client & other clients on the unit.

The nurse observes that a client is psychotic, pacing, & agitated & is making aggressive gestures. The client's speech pattern is rapid, & the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

Provide safety for the client & other clients on the unit

A teenager wrecks the family car by rear-ending a truck turning left. The teen says. "It wasn't my fault. I came over the rise & that truck was just sitting there. It was his fault for turning left." What defense mechanism is the teen using to deal with his situation?

Rationalization

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:

Re-experiencing recollections of the trauma

A CEO was admitted to the orthopedic ward with pelvic fracture, wrist fracture, & multiple contusions & abrasions from an auto accident. She yells for the nurse every 5 min, refuses to use her call light, & breaks out in tears when she doesn't get her way. This coping behavior is termed:

Regression

A woman comes into the emergency room following an assault. Her symptoms include hyperventilation, pacing, rapid speech, & headache. The nurse correctly determines that the client is experiencing which level of anxiety?

Severe

The nurse is instructing a wife to give insulin injections to her husband. The wife is unable to sit still, frequently asks to repeat parts of the instruction for understanding, & sighs often with rapid respirations. What degree of anxiety is the wife experiencing?

Severe

A nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client?

Slowed walking & talking

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from which condition?

Somatization disorder

A crisis occurs when a person:

Suffers a stressor & responds with ineffective coping efforts

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings r/t loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

A nurse is collecting data from a client in crisis & is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide?

The client has an immediate plan for a suicide attempt

The nurse is reviewing the record of a client admitted to the mental health unit & notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand & 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, the nurse expects which?

The client presents a harm to self

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

The client will participate in the treatment plan

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

The false belief that one is being singled out for harm by others

The nurse is admitting a client who has a history of bipolar disorder to the hospital, & ER doc 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.

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

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

- Communicate expected behaviors to the client - Assist the client in developing means of setting limits on personal behavior - Follow through about the consequences of behavior in a non-punitive manner - Be clear with the client regarding the consequences of exceeding limits set regarding behavior

A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is accurate regarding depression & the older client? Select all that apply.

- Depression in an older person is likely to have physical manifestations. - Some indications of dementia may actually originate as depression. - Suicide is a frequent cause of death among the older population.

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door & is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

Denial

A nurse working in the long-term care facility understands which of the following concepts r/t depression in the older client?

Depression in the older client is often undertreated.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply

- Communicate expected behaviors to the client - Assist the client in developing means of setting limits on personal behavior. - Follow through about the consequences of behavior in a nonpunitive manner. - Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

The LPN is assisting the RN in admitting a client with an exacerbation of schizophrenia & knows that which s/s displayed by the client are considered positive symptoms? Select all that apply.

- Hallucinations - Delusions - Neologisms

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate & who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

- Incoordination - Mental confusion - Muscle hyperirritability

Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.

- Monitor VS - Provide a safe environment - Provide reality orientation as appropriate - Address hallucinations therapeutically

A client comes to the ER following an assault & is extremely agitated, trembling, & hyperventilating. Which initial nursing action is appropriate?

Remain with the client until the anxiety decreases

The nurse is assigned to assist in the care of a client with OCD. The nurse should place 1st priority on which action when planning care for this client?

Establish a trusting nurse-client relationship

The nurse in the mental health unit reviews the therapeutic & nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

- Restating - Listening - Maintaining neutral response - Providing acknowledgment & feedback

A client experiencing a severe major depressive episode is unable to address ADLs. The appropriate nursing intervention is which?

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

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive & threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which?

Escort the manic client to his/her room

A suicidal client is admitted to the hospital. The nurse reviews the nursing care plan & notes documentation of a nursing diagnosis of dysfunctional grieving r/t the loss of a spouse. The client progresses well & is approaching discharge. Which of the following is an appropriate outcome for this client?

The client verbalizes stages of grief & plans to attend a community grief group

A nurse is assisting with the data collection on a pt admitted to the psychiatric unit. The nurse reviews the data obtained & identifies which of the following as a priority concern?

The pt's report as a priority of suicidal thoughts