mental health NCLEX
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 a helping one."
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
A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?
Feed, bathe, and dress the client as needed until the client can perform these activities independently.
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
The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client?
"Tell me more about what happened that causes you to feel like the rape just occurred."
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, which is the most appropriate question to ask?
"What leads you to seek help now?"
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 present at the time should respond with which question or statement?
"Are you fearful and think that others may want to hurt you?"
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?
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 is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client?
Amnesia of events occurring near the period of the therapy is common.
The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.
Punishment (e.g., punishment applied after the client has had an alcoholic drink) Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus
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 admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply.
Set limits on behavior. Distract or redirect the client. Decrease environmental stimulation. Provide high caloric nutritional intake.
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.
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.
A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?
The mother should restrict the amount of chocolate and caffeine products in the home.
A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?
Use a night light and turn off the television.
The nurse caring for a client with schizophrenia prepares to document which signs/symptoms exhibited by the client as negative? Select all that apply.
Avolition Anergia
The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply?
"Within a few hours"
The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic?
"You haven't had an appetite at all?"
The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.
Avoidance Hyperarousal Reexperiencing
The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs should the nurse observe with tardive dyskinesia?
Abnormal movements and involuntary movements of the mouth, tongue, and face
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
A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.
Cutoffs Conflict Over involvement
A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply.
Depression Substance abuse Adverse childhood events Posttraumatic stress disorder (PTSD)
A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention?
Escort the manic client to his or her room.
Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.
Medication management Monitoring and documenting behavioral changes Notifying the health care provider of behavioral changes Planning care for the needs of those clients with mental illness
Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.
Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate
The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?
Observe for excessive exercise.
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms?
Hypertension, disorientation, hallucinations
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 assigned to care for a client experiencing disturbed thought processes. 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?
Open-ended questions and silence
The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client?
Ping-pong
The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?
Place the client on one-to-one suicide precautions.
The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?
"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"
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?"
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." "I have bruises all over my body. I am frequently clumsy and fall a lot. "My boyfriend yells and accuses me of having an affair if I am late after work."
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 is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk.
Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.
Poor limit setting Staff inexperience Provocative or controlling staff Arbitrary revocation of privileges
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 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.
A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?
Inform the client that she is being secluded to help regain control of herself.
A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse?
"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"
An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?
"I am concerned about you. Are you now or have you ever been abused?"
During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response?
"Have you shared your concerns with the police?"
The student nurse is being taught by the registered nurse (RN) how to collect 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 response by the student nurse indicates a need for further teaching?
"I am the nurse and, as such, I'll have you know that all information is kept confidential."
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."
The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?
"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."
