NCLEX REVIEW PSYCH/MENTAL HEALTH

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

"I cannot discuss any client situation with you."

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?

"I don't feel like hurting myself anymore."

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

"What do you mean by that?"

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?

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

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."

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?

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

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

1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgment and feedback

The nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior?

Improvement

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.

A high achiever, Personality changes, Lanugo over the back and extremities

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?

Posttraumatic stress disorder (PTSD)

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

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

Actions

A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which?

Admitting to having a problem

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.

Age less than 32 years Practicing a religion Married over 10 years

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

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

Client threatened to commit suicide. Client threatened to kidnap his spouse.

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.

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

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 is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

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?

Identify recent behaviors or accomplishments that demonstrate skill or ability.

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and 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

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 caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions to this client's medication refusal? Select all that apply.

Notify the health care provider. Document the refusal of medication. Ask the client why he is refusing the medication.

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client.

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?

Reward the client when a desired behavior is performed.

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?

Risk for aspiration

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 is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a DVD and a cherished autographed picture of the performer.

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 client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse should focus the initial data collection on which information?

The presence of existing suicidal thoughts

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 client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

Weight loss

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

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?

Evidence of the client's altered and distorted body image

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

Explaining procedures to be completed and why the procedures are necessary

The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client's symptoms are compatible with which anxiety disorder?

Obsessive-compulsive disorder

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the health care provider is notified.

The nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which problem?

Social phobia

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply.

Speak slowly, Use simple statements, Provide the client with high-calorie beverages.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?

Use a night light and turn off the television.

A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's best response?

"I don't hear the voices, but I can see how upsetting it must be for you."

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

"I hid my silverware from dinner last night.", "I know that by this time tomorrow all my troubles will be over."

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 determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say which?

"I no longer feel that I deserve the beatings my husband inflicts on me."

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 who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

1. Sit by client's bed holding his or her hand. 2. Reminisce with the client and sharing a humorous story that the client enjoys. 3. The nurse asks: "What can I do, that might make you feel more comfortable today?" 5. The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6. The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

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

A client with severe depression and cancer

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."

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?"

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and helping one."

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?

"What do you mean by that?"

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time?

"You sound very unhappy. Are you thinking of harming yourself?"

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

Lanugo Amenorrhea

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.

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

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

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.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?

The client shampoos and dries the hair, freeing it of all hair spray and creams.

A client is scheduled to have electroconvulsive therapy (ECT). Which information would the nurse tell the client?

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

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

"Let me know if you change your mind, and I'll get you something to eat."

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

"I notice you are wearing a blue shirt." 2. "Do you have any plans of harming yourself?" 4. "I will sit here with you even if you choose not to talk with me."

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is which?

"What leads you to seek help now?"

The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa?

A client with pneumonia

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 who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

Assist in making appropriate referrals.

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

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

Constantly neglects personal grooming

As the nurse approaches a client who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the Federal Crime Scene Investigation Unit; I can tell by the way you are walking." This is an example of which alteration in thinking?

Delusion

The nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which signs and symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is which?

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

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

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

A mental health nurse caring for a client diagnosed with mania selects which activity for this client?

Going for a walk with staff

When admitted to the inpatient mental health unit, a client dramatically states, "I am a member of England's royal family." How should the nurse document this behavior?

Grandiose delusions

The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem?

Maintain a well-groomed appearance.

The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?

Makes excuses for not leaving the house

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.

Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils Ensuring that her diet consists of bland, easy-to-digest foods and beverages

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.

Misplacing a valuable object, Difficulty coming up with the right word

The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?

Provide for safety by recognizing the level of client anxiety and setting limits.

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.

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

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 is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?

Sit beside the client in silence with occasional open-ended questions.

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?

Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?

Stay with the client at all times.

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 is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?

Tell the client that he may talk about his anger but cannot act on it during the group session.

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the health care provider will be contacted regarding discharge.

The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?

Telling a friend that this employee hates her

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.

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

The client has the right to demand and obtain release from the hospital.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide.

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 mental health nurse on the evening shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect which statement is an aspect of the client's care?

The client is in need of psychiatric treatment.

The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care?

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

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

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.