Mental Health - NCLEX

A client is unwilling to get 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 spouse asks the nurse, " what is the name of my wife's disorder?"Which answer should the nurse give to the spouse? 1. agoraphobia 2. hematophobia 3. claustrophobia 4. hypochondriasis

1. agoraphobia

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SELECT ALL THAT APPLY 1. communicate expected behaviors to the client 2. follow through about the consequences of behavior in a nonpunitive manner 3. ensure that the client knows that he or she is not in charge of the nursing unit 4. assist the client with developing a means of setting limits on personal behavior 5. be clear with the client regarding the consequences of exceeding limits set regarding behavior

1. communicate expected behaviors to the client 2. follow through about the consequences of behavior in a nonpunitive manner 4. assist the client with developing a means of setting limits on personal behavior 5. be clear with the client regarding the consequences of exceeding limits set regarding behavior

The nurse is collecting data from a client and the clients spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication? 1. dementia 2. schizophrenia 3. seizure disorder 4. OCD

1. dementia

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting " Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? 1. denial 2. projection 3. regression 4. rationalization

1. denial

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? 1. feed, bathe, and dress the client as needed until the client can perform these activities independently 2. offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living 3. structure the clients day so that adequate time can be devoted to the clients assuming responsibility for the activities of daily living 4. have the clients peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu.

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

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression.The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? SELECT ALL THAT APPLY 1. figs 2. yogurt 3. crackers 4. aged cheese 5. tossed salad 6. oatmeal cookies

1. figs 2. yogurt 4. aged cheese

The nurse is assisting with planning the care of 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? 1. one-to-one suicide precautions 2. suicide precautions, with 30 min checks 3. checking the whereabouts of the client every 15 min 4. asking that the client to report suicidal thoughts immediately

1. one-to-one suicide precautions

The nurse is assigned to care for a client experiencing disturbed thought process. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1. open-ended questions and silence 2. focusing on self-disclosure regarding food preferences 3. stating the reasons that the client may not want to eat 4. offering opinions about the necessity of adequate nutrition

1. open-ended questions and silence

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? SELECT ALL THAT APPLY 1. restating 2. listening 3. asking the client "why?' 4. maintaining neutral responses 5. giving advice, approval, or disapproval 6. providing acknowledgement and feed back

1. restating 2. listening 4. maintaining neutral responses 6. providing acknowledgement and feed back

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, which would the nurse expect to note? 1. the client presents a harm to self 2. the client request the admission 3. the client consented to the admission 4. the client provided written application to the facility for admission

1. the client presents a harm to self

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up and the level is 3.0. The nurse knows that this is which level? 1. toxic 2. normal 3. slightly above normal 4. excessively below normal

1. toxic

a client taking buspirone (buspar) for 1 month returns to the clinic for a follow-up visit. which of the following would indicate medication effectiveness? 1.no rapid heartbeats or anxiety 2.no paranoid thought process 3.no thought broadcasting or delusions 4.no reports of alcohol withdrawal symptoms

1.no rapid heartbeats or anxiety

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond with which statement? 1. the technician is not going to hurt you but is going to help you 2. are you fearful and think that others may want to hurt you? 3. what makes you think that the technician wants to hurt you? 4. the technician will leave and come back later for you blood

2. are you fearful and think that others may want to hurt you?

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? 1. a puzzle 2. drawing 3. checkers 4. paint by number

2. drawing

The nurse is performing a follow up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication? 1. cardiovascular symptoms 2. gastrointestinal dysfunctions 3. problems with mouth dryness 4. problems with excessive sweating

2. gastrointestinal dysfunctions

A 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, which would the nurse expect to note? 1. the client will be angry and will refuse care 2. the client will participate in the treatment plan 3. the client will be very resistant to treatment measures 4. the client's family will be very resistant to treatment measures

2. the client will participate in the treatment plan

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine 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 clients home 4. a recent rape episode experienced by the client

2. the death of a loved one

A client with delirium becomes agitated and confused at night. The best INITIAL intervention by the nurse is which action? 1. move the client next to the nurses station 2. use a night light and turn off the TV 3. keep the TV and a soft light on during the night 4. play soft music during the night and maintain a well-lit room

2. use a night light and turn off the TV

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? 1. dialated pupils, tachycardia, and diaphoresis 2. yawning, irritability, diaphoresis, cramps, and diarrhea 3. tachycardia, hypertension, sweating, and marked tremors 4. depressed feelings, high drug craving, fatigue, and agitation

2. yawning, irritability, diaphoresis, cramps, and diarrhea

The nurse is preparing the client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1. plan short-term goals 2. identify expected outcomes 3. assist with making appropriate referrals 4. assist with developing realistic solutions

3. assist with making appropriate referrals

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record ,the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that tje admission was a voluntary one . The nurse reports the findings to the RN and expects that the RN will take which action? 1. call the client's family 2. persuade the client to stay for a few more days 3. contact the PHCP 4. tell the client that discharge is not possible at this time

3. contact the PHCP

A client was admitted to a medical unit with acute blindness. Many teat are performed , and there seems to be no organic reason why this client can not see. The nurse later learns that the client became blind after witnessing a hit and run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? 1. psychosis 2. repression 3. conversion disorder 4. dissociative disorder

3. conversion disorder

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? 1. identifying the client's ability to function 2. identifying the client's potential for self-harm 3. inquiring about the client's feelings that may affect coping 4. inquiring about the client's perception of the cause of the neighbors death

3. inquiring about the client's feelings that may affect coping

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1. engaging in immoral acts 2. always reinforcing self- approval 3. observing rigid rules and regulations 4. having the need to always make the right decision

3. observing rigid rules and regulations

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client would plan for which appropriate nursing intervention? 1. watch the behavior escalate before intervening 2. attempt to talk with the client to de-escalate the behavior 3. offer to take the client to an examination room until he or she can be treated 4. inform the client that he or she will be asked to leave if the behavior continues

3. offer to take the client to an examination room until he or she can be treated

A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hychloride to help them get better faster. The nurse understands that the client is now at risk for which problem? 1. insomnia 2. weight gain 3. seizure activity 4. orthostatic hypotension

3. seizure activity

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? 1. ask direct questions to encourage talking 2. leave the client alone and intermittently check on them 3. sit beside the client in silence and verbalize occasional open-ended questions 4. take the client into the day room with other clients so they can help watch him

3. sit beside the client in silence and verbalize occasional open-ended questions

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data , the nurse should identify which as a PRIORITY concern? 1. the client's report of not eating or sleeping 2. the presence of bruises on the client's body 3. the client's report of self-destructive thoughts 4. the family member is disapproving of the treatment

3. the client's report of self-destructive thoughts

A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review with the use of this medication? 1. platelet count 2. cholesterol level 3. white blood cell count 4. blood urea nitrogen level

3. white blood cell count

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says " I'm in treatment and I have served my time. Now this group has posters all over my neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? 1. when children are hurt the way you hurt them, people want you isolated 2. you're lucky it doesn't escalate into something pretty scary after your crime 3. you understand that people fear for their children , but you're feeling unfairly treated? 4. you seem angry, but you have committed serious crimes against several children, so your neighbors are frightened

3. you understand that people fear for their children , but you're feeling unfairly treated?

A client says to the nurse " I'm going to die,and I wish my family would stop hoping for a cure! I get so angry when they carry on like this ! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1. have you shared your feelings with your family? 2. I think we should talk about your anger with your family 3. you're feeling angry that your family continues to hope for you to be cures? 4. well, it sounds like you are being pretty pessimistic. After all, years ago people died of pneumonia

3. you're feeling angry that your family continues to hope for you to be cures?

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? 1. a crisis state indicates that the individual is suffering from a mental illness 2. a crisis state indicated that the individual is suffering from an emotional illness 3. presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis 4. a client's response to a crisis is individualized and what constitutes a crisis for one person may not constitute for another person

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

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? 1. facing the client when providing care 2. ensuring that a security officer is within the immediate area 3. keeping the door to the clients room open when with the client 4. assigning the client to a room at the end of the hall to prevent disturbing the other clients

4. assigning the client to a room at the end of the hall to prevent disturbing the other clients

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need for FURTHER teaching? 1. dental erosion 2. electrolyte imbalances 3. enlarged parotid glands 4. body weight well below ideal range

4. body weight well below ideal range

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 RN and expects that the RN will take which action? 1. call the client's family 2. place the client in seclusion immediately 3. inform the client that seclusion has not been prescribed 4. get a written prescription from the PHCP and obtain an informed consent

4. get a written prescription from the PHCP and obtain an informed consent

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? 1. hypotension, ataxia, vomiting 2. stupor, agitation, muscular rigidity 3. hypotension, bradycardia, agitation 4. hypertension, disorientation, hallucinations

4. hypertension, disorientation, hallucinations

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1. poor dietary choices 2. lack of exercise and poor diet 3. inadequate dietary intake and dehydration 4. psychomotor retardation and side effects of medication

4. psychomotor retardation and side effects of medication

A 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 of the following thoughts? 1. the false belief that one is a very powerful person 2. the false belief that one is a very important person 3. the false belief that one's partner is being unfaithful 4. the false belief that one is being singled out for harm by others

4. the false belief that one is being singled out for harm by others

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is MOST important for the nurse to determine before administration of the medication? 1. a history of hyperthyroidism 2. a history of diabetes insipidus 3. when the last full meal was consumed 4. when the last alcoholic drink was consumed

4. when the last alcoholic drink was consumed

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "when will the fist signs of withdrawal appear?" The nurse should give which replay? 1. 7 days 2. 14 days 3. 21 days 4. within a few hours

4. within a few hours