Mental Health NCLEX Questions
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. provide safety for the client and other clients one the unit. 2. provide the clients on the unit with a sense of comfort and safety. 3. assist the staff in caring for the client in a controlled environment. 4. offer the client a less stimulating area to calm down in and gain control.
1
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. hydrochondriasis
2
A client who has been taking bus-irons 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 thought process 2. rapid heartbeat or anxiety 3. alcohol withdrawal symptoms 4. thought broadcasting or delusions
2
The nurse in the emergency department is 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 The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. signs of depression 2. normal reactions to a devastating event 3. evidence that the client is a high suicide risk 4. indicative of the need for hospital admission
2
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. witnessing a murder 2. the death of a loved one 3. a fire that destroyed the client's home 4. a rape episode experienced by the client
2
The nurse notes that a client with schizophrenia and receiving an antipsychotic mediation is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. parkinsonism 2. tardive dyskinesia 3. hypertensive crisis 4. neuroleptic malignant syndrome
2
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? 1. suppressing feelings of anxiety 2. identifying anxiety-producing situations 3. continues contact with a crisis counselor 4. eliminating all anxiety from daily situations
2
A manic client begins to make sexual advance towards visitors in the dayroom. 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 interventions should the nurse implement? 1. place the client in seclusion for 30 mins. 2. tell the client that the behavior is inappropriate 3. escort the client to their room, with the assistance of other staff 4. tell the client that their telephone privileges are revoked for 24 hours
3
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. adhering to the mandatory abuse-reporting laws 2. notifying the case worker of the family situation 3. removing the client from any immediate danger 4. obtaining treatment for the abusing family member
3
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion," 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."
3
A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. " The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"
3.
A client with schizophrenia has been started on the medication 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 studies 4. white blood cell count
4
A nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. get adequate sunlight 2. continue driving as usual 3. avoid foods rich in potassium 4. get up slowly when changing positions
4
The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "Ill go ti support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."
4
