Mental Health NCLEX Practice Questions

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SATA a. Communicate expected behaviors to the client b. Ensure that the client knows that they are not in charge of the nursing unit c. Assist the client in identifying ways of setting limits on personal behaviors d. Follow through about the consequences of behavior in a non-punitive manner e. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups f. Have the client state the consequences for behaving in ways that are viewed as unacceptable

A, C, D, F

The nurse observes that a client is pacing, agitated and presenting aggressive gestures. The clients speech pattern is rapid, and affect is belligerent. Based on these observations which is the nurse's immediate priority of care? a. Provide safety for the client and other clients on the unity b. Provide the clients on the unit with a sense of comfort and safety c. Assist the staff in caring for the client in a controlled environment d. Offer the client a less stimulating area in which to calm down and gain control

a. Provide safety for the client and other clients on the unity Safety first

A client is unwilling to go to his church because his ex-girlfirend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? a. Avoidant b. Borderline c. Schizotypal d. Obsessive-complusive

a. avoidant Avoidant - social withdrawal, extreme sensitivity to potential rejection Borderline - unstable mood, impulsive, unpredictable Schizotypal - abnormal thoughts, perceptions, speech, behavior Obsessive-Compulsive - perfection, control, devotion to work

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? a. Increase socialization of the client with peers b. Avoid using a whisper voice in front of the client c. Begin to educate the client about social supports in the community d. Have the client sign a release of information to appropriate parties for assessment purposes

b. Avoid using a whisper voice in front of the client Client is distrustful and suspicious

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? a. Suppressing feelings of anxiety b. Identifying anxiety-producing situations c. Continuing contact with a crisis counselor d. Eliminating all anxiety from daily situations

b. Identifying anxiety-producing situations Recognizing what causes anxiety allows client opportunity to prepare to cope with the situation.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? a. Psychosis 2. Repression c. Conversion disorder d. Dissociative disorder

c. Conversion disorder Conversion disorder - alteration or loss of a physical function that cannot be explained by known patho mechanism. Patient witnessed an accident so disturbing they became blind as defense.

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? a. I don't believe this is true. b. The guards are not out to kill you c. Do you feel afraid that people are trying to hurt you? d. What makes you think the guards were sent to hurt you?

c. Do you feel afraid that people are trying to hurt you? This option makes a connection with what the client is experiencing but doesn't emphasize the delusion as a discussion point.

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? a. My medications will help my anxious feelings b. I'll go to support group and talk about what I am feeling c. I need to get enough sleep and eat well to help prevent feeling anxious d. When I have command hallucinations, I'll call a friend and ask him what to do

d. When I have command hallucinations, I'll call a friend and ask him what to do The client needs to call the provider or nurse, not a friend

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? a. Setting limits on the client's behavior b. Asking the client to leave the group session c. Asking another nurse to escort the client out of the group session

a. Setting limits on the client's behavior The key word is initially. The client needs to understand the expected behavior. If the disruption continued C would be the next option.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? a. Move the client next to nurses station b. Use an indirect light source and turn off television c. Keep television and a soft light on during the night d. Play soft music during the night and maintain a well-lit room

b. Use an indirect light source and turn off television Low stimulating environment is important. Adding TV and music may add to confusion. Moving pt next to nurses station may become necessary for fall risk but is not first choice.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? a. Chess b. Writing c. Ping pong d. Basketball

b. Writing Solitary activity with little physical activity: writing, journaling, walks with staff, painting reduce stimuli

A manic client begins to make sexual advances toward visitors in the day room. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? a. Place the client in seclusion for 30 minutes b. Tell the client that the behavior is inappropriate c. Escort the client to their room, with the assistance of other staff d. Tell the client that their telephone privileges are revoked for 24 hours

c. Escort the client to their room, with the assistance of other staff The client is at risk for injury to self and others and should be removed. B was already tried. D is inappropriate.

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? a. Encouraging quiet reading and writing for the first few days b. Identification of physical activities that will provide exercise c. No socializing activities until the client participates in milieu d. A structured program of activities in which the client can participate

d. A structured program of activities in which the client can participate Depression can cause withdrawal and poor self-esteem. Structured activities that the client enjoys can help.