2024 NCLEX Mental Health Exam/ Mental Health Exam New Latest Version with All Questions, Exams of Nursing

Download 2024 NCLEX Mental Health Exam/ Mental Health Exam New Latest Version with All Questions and more Exams Nursing in PDF only on Docsity! 2024 NCLEX Mental Health Exam/ Mental Health Exam New Latest Version with All Questions from Actual Past Exam and 100% Correct Answers The school nurse is called to the classroom to assist with a 7-year-old with attention- deficit hyperactivity disorder who is throwing books and hitting the other children. What is the BEST INITIAL action for the nurse to take? 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors ---------- Correct Answer ----------- 2 The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water." ---------- Correct Answer ----------- 3 A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing INTERVENTIONs should the nurse include in the client's plan of care with regard to the delusional thinking? SELECT ALL THAT APPLY. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions ---------- Correct Answer --------- -- 2 The nurse reviews the social history of an adolescent client and understands that which behaviors support a diagnosis of conduct disorder? SELECT ALL THAT APPLY. 1. Blames voices when confronted about misbehavior 2. Fluctuates moods between depression and elation 3. Inserts thumbtacks into the feet of a neighbor's dog 4. Taps a pen on the desk to deliberately annoy peers 5. Vandalizes a painting in a local art museum ---------- Correct Answer ----------- 3,5 The registered nurse discusses discharge planning with the spouse of an 80-year-old client diagnosed with chronic obstructive lung disease and chronic respiratory failure. The client is bedbound, has a tracheostomy, is on a ventilator, and requires suctioning at least 3 times daily. The spouse says to the nurse, "l've been helping out here, so I'm sure I can manage my spouse's care at home." The nurse's response is based on which understanding? 1. Caregiver strain is a risk for any family member who cares for a loved one at home 2. Client needs to be placed in a skilled nursing facility 3. Clients on ventilators cannot be cared for at home 4. Discharging the client to the home is an unsafe plan ---------- Correct Answer ----------- 1 A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini... I can get out of anything. There could be trouble now." Which of the following is the BEST response to this client? 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed. 4. "What kind of trouble are you thinking about?" ---------- Correct Answer ----------- 4 A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 KEY clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death ---------- Correct Answer ---- ------- 3 The registered nurse is leading a support group for partners of military veterans suffering from postiraumatic stress disorder (PTSD) A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that MOST individuals with PTSD report which symptoms? 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness ---------- Correct Answer ----------- 2 A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance ---------- Correct Answer ----------- 4 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest." ---------- Correct Answer ----------- 3,4,5 The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills ---------- Correct Answer ----------- 4 The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes ---------- Correct Answer ----------- 4 A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the BEST response by the nurse? 1. "How could your fiancé be wonderful after saying those things to you?' 2. "I think you are better off without your fiancé." 3. "Maybe the breakup was for the BEST." 4. "Tell me how you felt when your fiancé broke up with you." ---------- Correct Answer ----------- 4 Which statement made by the nurse during a therapy session demonstrates a need for FURTHER INSTRUCTION regarding effective therapeutic communication techniques? 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?" ---------- Correct Answer ----------- 4 The daughter of an 80-year-old client recently diagnosed with Alzheimer disease says to the nurse, "I can anticipate getting this disease myself at some point." What is the BEST response by the nurse? 1. "Have you suffered any recent head trauma?" 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan for your future care." 4. "Not necessarily. The strongest known risk factor for Alzheimer disease is age." ------- --- Correct Answer ----------- 4 An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation; confusion, and disorientation to time and place. What is the MOST IMPORTANT nursing action? 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation ---------- Correct Answer --------- -- 3 The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder Which assessments would support this diagnosis? SELECT ALL THAT APPLY. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood ---------- Correct Answer ----------- 1,2,4,5 The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the PRIORITY nursing action? 1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors 4. Provide verbal explanations of what to expect during hospitalization ---------- Correct Answer ----------- 2 The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? SELECT ALL THAT APPLY. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime ---------- Correct Answer -- --------- 1,4,5 The nurse is caring for a client with bulimia nervosa. Which is the MOST IMPORTANT time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours ---------- Correct Answer ----------- 1 The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is MOST consistent with the diagnosis of delirium? 1. Client is alert but disoriented to time 2. Client is inattentive and hallucinating 3. Client reports decreased enjoyment in previously pleasurable activities 4. Family reports a gradual progressive inability to remember recent events ---------- Correct Answer ----------- 2 The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the BEST PRIORITY response by the nurse? 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?" ---------- Correct Answer ----------- 2 A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the BEST response by the nurse? 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia." ---------- Correct Answer ----------- 4 A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for MOST of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the BEST nursing action? 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room ---------- Correct Answer --------- -- 2 A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the BEST response by the nurse? 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "When talking with my child, I should not be multi-tasking." ---------- Correct Answer -- --------- 3 A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at GREATEST RISK for the development of delirium? 1 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3 60-year-old client with type Il diabetes. 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis ---------- Correct Answer ----------- 4 A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which INTERVENTIONs and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking ---------- Correct Answer ----------- 1,4,5,6 A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad ---------- Correct Answer ----------- 2 A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the PRIORITY action for the client's nursing care plan? 1. Assign different staff members to care for the client each day 2. Continue assigning the clients stated preferred nurse to care for the client 3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors ---------- Correct Answer ----------- 1 The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply. 1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago 3. Has a gun at home 4. Married with 3 children 5. Participation in religious activities 6. Unemployed and unable to find a job ---------- Correct Answer ----------- 1,2,3,6 The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the MOST APPROPRIATE response by the nurse? 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "MOST people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs." ---------- Correct Answer ----------- 3 Which client BEST demonstrates recovery associated with a mental illness? 1. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs 2. One who is receiving holistic care that addresses both physical and psychosocial needs 3. One who lives, works, and is involved with family and friends to the HIGHEST level of ability 4. One who, while diagnosed with a mental illness, is able to demonstrate hope for the future ---------- Correct Answer ----------- 3 Which client statement demonstrates mental health well-being when considering stress and anxiety? 1. "I know that relaxation techniques help me deal with my life's stress and anxiety." 2. "I understand stress and anxiety because my family has a history of depression." 3. "You must understand that stress and anxiety affect everyone's life." 4. "You should identify and then avoid those things that cause you stress and anxiety." ---------- Correct Answer ----------- 1 A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the BEST recreational activity for this child? 1. Childs favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay ---------- Correct Answer ----------- 2 A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation MOST LIKELY caused the client to seek therapy? 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months ---------- Correct Answer ----------- 2 A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the BEST response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up." ---------- Correct Answer ----------- 1 A college student finds a roommate mumbling and huddling in the corner of the room. The student brings the roommate to the emergency department, where the roommate is tentatively diagnosed with schizophrenia. The treatment plan includes hospitalization on the acute psychiatric unit and initiation of anti-psychotropic medication therapy. The client refuses to be admitted. Which of the following statements about hospital admission is true for this client? 1. If the client refuses to cooperate with the treatment plan, the client can be involuntarily committed. 2. If the treatment team determines the client poses danger to self or others, the client can be involuntarily committed. 3. The client can be involuntarily committed for observation and treatment if the roommate can provide consent. 4. The diagnosis of schizophrenia alone justifies the need for involuntary commitment. - --------- Correct Answer ----------- 2 The 17-year-old child of a client being treated for alcoholism tells the nurse that the parent's disease and behavior have taken a toll on the whole family the child is especially concerned about a 13-year-old sibling who is having trouble in school. The nurse should provide the child with information about what resource? 1. Adult Children of Alcoholics (ACOA) 2. Alateen 3. Alcoholics Anonymous (AA) 4. National Association for Children of Alcoholics (NACOA) ---------- Correct Answer ---- ------- 2 The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What INITIAL action should the triage nurse take? 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave ---------- Correct Answer ----------- 4 An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the MOST helpful? 1. "I am busy right now but can stay for a few minutes." 2. "I can call the clergy to come sit with you." 3. "I can stay and sit with you if you would like." 4. "I don't think I should interrupt your family time." ---------- Correct Answer ----------- 3 A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the MOST APPROPRIATE activity for the client? 1. A board game with a staff member 2. Participation in a group songfest 3. Planning a unit picnic 4. Playing Bingo with other clients ---------- Correct Answer ----------- 1 After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the BEST response by the nurse? 1. "But you look so thin." 2. "I don't see you that way; you are making progress toward a healthy weight." 3. "If you continue to gain weight at this rate, you will be able to go home soon." 4. "You are not fat; it's all in your imagination." ---------- Correct Answer ----------- 2 A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the BEST response by the nurse? 1. "I'm sorry. I should have reminded you to sign in" 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?" ---------- Correct Answer ----------- 3 The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the BEST reply to this client? 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that's what he meant?" 3. "The health care provider does not know what he's talking about. I'll give you the information my health care provider used." 4. "Why do you think he said that?" ---------- Correct Answer ----------- 1 The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which INTERVENTIONs would be included in the plan of care? SELECT ALL THAT APPLY. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area ---------- Correct Answer ----------- 2,3,5 A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the BEST action by the nurse? 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly ---------- Correct Answer ----------- 2 A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today. They are so angry with me." Which of the following is the BEST response by the nurse? 1 "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?" ---------- Correct Answer ----------- 4 A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead I can't believe this is happening." What is the BEST response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better" ---------- Correct Answer ----------- 3 The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room" Which statement BEST explains the client's behavior? 1. The client has a problem with authority figures 2. The client has an intense need to control the environment 3. The client is hearing voices 4. The client is trying to control anger ---------- Correct Answer ----------- 2 A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?" ---------- Correct Answer ----------- 3 The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse PRIORITIZE ? 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger ---------- Correct Answer ----------- 3 Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin." ---------- Correct Answer ----------- 3 A client hospitalized for anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which nursing actions are appropriate for promoting weight gain in this client? SELECT ALL THAT APPLY. 1. Determine minimum goals for daily caloric intake and weekly weight gain 2. Do not allow client to make food choices 3. Restrict privileges if weight loss occurs 4. Reweigh client on request 5. Set limits on physical activities 6. Sit with client during meals and discuss nutritional value of served foods ---------- Correct Answer ----------- 1,3,5 A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the