Mental Health NCLEX- PN

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?

"Discussing suicide with a client is not harmful."

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this-it's private and personal." Which statement by the nurse indicates a therapeutic response

"I know that some of these questions are difficult for you, but as the nurse, I must legally respect your confidentiality.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be the most appropriate?

"What do you and your husband believe is the right thing for your children?"

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent?

An informed consent needs to be obtained from the client.

Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy

Aversion therapy

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?

Client involvement in goal setting

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 activities of daily living (ADL) and poor nutritional intake

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

Contracts and immediate available crisis resources

The nurse working in the long-term care facility understands which concept related to depression in the older client?

Depression in the older client is often undertreated.

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place first priority on which action when planning care for this client?

Establish a trusting nurse-client relationship.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client?

Goals and objectives

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and 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 taking which action?

Increasing the level of suicide precautions

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which is the therapeutic nursing response?

It must be hard to accept that she has passed away."

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.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

The nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is which?

Ping Pong

The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client?

Provide authority, action, and participation

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?

Reexperiencing recollections of the trauma

A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. Which action should the nurse implement?

Remain with the client at all times.

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?

Remove both clients to a separate, safe location.

A woman comes into the emergency department following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety?

Severe

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?

Share the observation with the client and help the client recognize his or her feelings.

A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with which?

Somatization disorder

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

Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?

Stay with the client until the medication becomes effective.

The nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?

Suggest that the client stop talking and try listening to others.

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which should the nurse assigned to care for the client do first?

Take the client to a quiet room

The 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 related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

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

The client has an immediate plan for a suicide attempt.

A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop for which reason?

The client is unconsciously attempting to control unpleasant thoughts or feelings.

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?

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

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma

The nurse in the emergency department is assisting in 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. Which interpretation should the nurse make of these behaviors?

They are expected reactions to a devastating event.

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, which is important for the nurse to understand

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client?

Writing

The nurse is employed in a mental health clinic that specifically manages somatization disorders. The nurse understands that which is a characteristic of a somatization disorder

The client has multiple physical complaints.

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?

Distancing

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 least likely to be helpful to this client at this time?

Initiate confinement measures.

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

The nurse is preparing a client who was hospitalized for depression for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client as an indication that further teaching is needed?

"I know that I won't become depressed again."

The nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feel regret?"

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?

"Tell me about your difficulty sleeping."

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 has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

The 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 information is accurate regarding depression and the older client? Select all that apply.

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

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?

Altered thought processes

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

Beginning stage

The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate

Develops a relationship to help reduce the frequency of the delusions

A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility. The nurse should use which piece of information when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.

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

Inflexibility and rigidity

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which?

Protection from the risk of intimacy

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?

Quietly approach the client, escort her to her room, and assist her in getting dressed.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior?

The client is displaying typical behaviors that can occur during termination.

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection should focus on which information?

The physical condition of the client

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach?

Help the client identify and examine dysfunctional thoughts and beliefs.

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

The nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. Which should the nurse observe with tardive dyskinesia

Abnormal movements and involuntary movements of the mouth, tongue, and face

A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous tests to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, which condition should the nurse suspect the client may be experiencing?

A conversion disorder

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 should be therapeutic?

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

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

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?

Do you recall needing to be hospitalized because you stopped your medication?"

Which is the best rationale for using group therapy as an accepted way of treatment of clients in the milieu?

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment.