Mental Health NCLEX-RN Exam New Latest Version Updated 2023, Exams of Nursing

Download Mental Health NCLEX-RN Exam New Latest Version Updated 2023 and more Exams Nursing in PDF only on Docsity! Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 1 / 4 1. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics.": 1."I no longer feel that I deserve the beatings my husband inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response be- cause it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 2 / 4 escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent. 2. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night, and maintain a well-lit room.: 2.Use an indirect light source and turn off the television. Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action. The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? -------- Correct Answer -------- "You must be feeling all alone at this point." 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? -------- Correct Answer -------- The mother should restrict the amount of chocolate and caffeine products in the home. A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply. -------- Correct Answer -------- Irritability Hypertension Gastrointestinal disturbances The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder? -------- Correct Answer -------- Body weight well below ideal range 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? -------- Correct Answer -------- Open-ended questions and silence 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? -------- Correct Answer -------- The client presents a harm to self. In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? -------- Correct Answer -------- Encourage the client to participate in a structured daily program of activities. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 5 / 4 Incessant talking that includes sexual innuendos A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action? -------- Correct Answer -------- Call for the registered nurse. The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis? -------- Correct Answer -------- "What leads you to seek help now?" The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention? -------- Correct Answer -------- Contracts and immediate available crisis resources The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group? -------- Correct Answer -- ------ "The leader of this self-help group is the nurse or psychiatrist." A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care? -------- Correct Answer -------- Avoid joking or laughing in the presence of the client. The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? -------- Correct Answer -------- "What is causing you to become agitated?" A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time? -------- Correct Answer -------- "What is causing you to become agitated?" 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? -------- Correct Answer -------- Writing The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply. -------- Correct Answer -------- Denial Confabulation Perseveration Avoidance of questions The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? -------- Correct Answer -------- Examine and treat the wound sites. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 6 / 4 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? -------- Correct Answer -------- Maintain a well-groomed appearance. When caring for a client who has been raped, which intervention should the nurse implement during the examination? -------- Correct Answer -------- Explaining procedures to be completed and why the procedures are necessary An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment? -------- Correct Answer -------- Suggest that the mother's boyfriend move out of the home. The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills? -------- Correct Answer -------- Driving under the influence (DUI) conviction resulted in a 1-year suspended license The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which? -------- Correct Answer -------- Suggest that the client stop talking and try listening to others. 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? -------- Correct Answer -------- "You seem very distressed over learning you have asthma." A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? -------- Correct Answer -------- Feed, bathe, and dress the client as needed until the client can perform these activities independently. A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need? -------- Correct Answer -------- Safety and security A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder? -------- Correct Answer -------- Altered thought processes 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. -------- Correct Answer -------- Set limits on behavior. Distract or redirect the client. Decrease environmental stimulation. Provide high caloric nutritional intake. 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? -------- Correct Answer -------- Keep the client talking and signal to another staff member to send help to the client. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 7 / 4 During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "You sound very upset. Are you thinking of hurting yourself?" The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. -------- Correct Answer -------- Stay with the client. Administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli. A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority? -------- Correct Answer -------- Risk for aspiration The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply. -------- Correct Answer -------- Refer to hallucinations as if they are real. Ask the client directly about the hallucinations. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices. The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply. -------- Correct Answer -------- Misplacing a valuable object Difficulty coming up with the right word A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply. -------- Correct Answer -------- Monitor airway. Notify the registered nurse (RN). Remain with the client to provide support. Administer a prescribed intramuscular (IM) antiparkinsonian medication. The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate? -------- Correct Answer -------- "What do you and your husband believe is the right thing for your children?" Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 10 / 4 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? -------- Correct Answer -------- The client has the right to demand and obtain release from the hospital. The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations? -------- Correct Answer -------- Discuss common fears and questions expressed by other clients with the same diagnosis. The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic? -------- Correct Answer -------- "Do you recall needing to be hospitalized because you stopped your medication?" The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply. -------- Correct Answer -------- Diaphoretic Temperature of 104.8° F Blood pressure of 210/130 mm Hg The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason? -------- Correct Answer -------- Protection from the risk of intimacy The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term? -------- Correct Answer -------- Psychodrama The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply. -------- Correct Answer -------- Respond to stimuli Conduct electrical impulses Release chemicals called neurotransmitters 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? -------- Correct Answer -------- Inquiring about the client's feelings that may affect coping Which client is most likely at risk to become a victim of elder abuse? -------- Correct Answer -------- A 90-year-old woman with advanced Alzheimer's disease A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? -------- Correct Answer -------- A client receiving diagnostic tests Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 11 / 4 A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose? -------- Correct Answer -------- Disulfiram 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? -------- Correct Answer -------- The client will resolve feelings of fear and anxiety related to the rape trauma. The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? -------- Correct Answer ------- - "What do you find difficult about this situation?" A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement? -------- Correct Answer -------- Remain with the client at all times. The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. -------- Correct Answer -------- Mutual learning Increased feedback Instilling a sense of belonging An opportunity to practice new skills in a relatively safe environment Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety? -------- Correct Answer -------- Stay with the client until the medication becomes effective. 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? -------- Correct Answer -------- Reward the client when a desired behavior is performed. 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. -------- Correct Answer -------- Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client. A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse? -------- Correct Answer ----- --- "When I tell my child to do something once, I don't expect to have to repeat it." 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? -------- Correct Answer -------- "Our relationship is a therapeutic and a helping one." 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? ----- --- Correct Answer -------- Fever, yawning, irritability, diaphoresis, and diarrhea Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 12 / 4 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? -------- Correct Answer -------- "I am the nurse and, as such, I'll have you know that all information is kept confidential." 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? -------- Correct Answer -------- A client with severe depression and terminal cancer 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? -------- Correct Answer -------- "I don't know about a religious cult. Are you afraid that people are trying to hurt you?" 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 would be therapeutic? -------- Correct Answer -------- "It's okay to grieve and be angry with your daughter and anyone else for a time." 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? -------- Correct Answer ------ -- "Within a few hours" 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. -------- Correct Answer -------- Avoidance Hyperarousal Reexperiencing 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? -------- Correct Answer -------- Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. 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? -------- Correct Answer -------- Reported hopelessness The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? -------- Correct Answer -------- Assist with making appropriate referrals. A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make? -------- Correct Answer -------- "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?" Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 15 / 4 A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic? -------- Correct Answer -------- "You seem very discouraged. Can you think of anything recently that went as you planned?" 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? -------- Correct Answer -------- Assigning the client to a room at the end of the hall to prevent disturbing the other clients 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. -------- Correct Answer -------- Depression Substance abuse Adverse childhood events Posttraumatic stress disorder (PTSD) The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care? -------- Correct Answer -- ------ Provide safety for both the client and other clients on the unit. The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client? -------- Correct Answer ------ -- "When the psychiatrist arrives on the unit, I will let her know that you have a question." 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. -------- Correct Answer -------- Cutoffs Conflict Over involvement 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? -------- Correct Answer -------- Place the client on one-to-one suicide precautions. 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? -------- Correct Answer -------- Sit beside the client in silence with occasional open-ended questions. 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 in response to this client's medication refusal? Select all that apply. -------- Correct Answer -------- Document the refusal of medication. 2. Notify the registered nurse. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 16 / 4 3. Ask the client why he is refusing the medication. 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? -------- Correct Answer -------- "I can see that you are upset. I'll be back in a few minutes to see how you are doing." 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? -------- Correct Answer -------- Identify recent behaviors or accomplishments that demonstrate skill or ability. 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? -------- Correct Answer -------- Share the observation with the client and help the client recognize his or her feelings. 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? -------- Correct Answer -------- Alcoholics Anonymous 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 wasn't around." Which response by the nurse would be appropriate at this time? -------- Correct Answer -------- "You sound very unhappy. Are you thinking of harming yourself?" 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? -------- Correct Answer -------- "You haven't had an appetite at all?" The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client? -------- Correct Answer -------- Ping-pong A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "Tell me about your difficulty sleeping." An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply. -------- Correct Answer -------- Is it in the best interest of society? Does its use violate the client's rights? Is this therapy in the best interest of the client? A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? -------- Correct Answer -------- Increasing the level of suicide precautions 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? -------- Correct Answer -------- Interrupt the client and offer to take her for a walk. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 17 / 4 A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? -------- Correct Answer -------- Assign a staff member to the client who will remain with him or her at all times. 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? -------- Correct Answer -------- "It seems as if you or your daughter feel regret?" The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply. -------- Correct Answer -------- Paralysis Blindness Paresthesia Movement disorder 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? -------- Correct Answer -------- The client will be introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? -------- Correct Answer -------- 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 the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? -------- Correct Answer -------- Contact the primary health care provider (PHCP). The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply. -------- Correct Answer -------- Zoophobia Xenophobia Agoraphobia Glossophobia 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? -------- Correct Answer -------- "It must be hard to accept that she has passed away." Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 20 / 4 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? -------- Correct Answer -------- The client's report of self-destructive thoughts While the nurse is providing care, a client angrily reports to the nurse that the primary health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client? -------- Correct Answer -------- "The primary health care provider would never lie to you." A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate? -------- Correct Answer -------- "Tell me more about what causes you to feel like the rape just occurred." The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply. -------- Correct Answer -------- Rigidity Inflexibility Repetitive thoughts Ritualistic behavior During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? -------- Correct Answer -------- A fear of leaving the house A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response? -------- Correct Answer -------- "What do you mean by that?" 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 finding? -------- Correct Answer -------- Evidence of the client's altered and distorted body image 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? -------- Correct Answer -------- Telling a friend that this employee hates her 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? -------- Correct Answer ---- ---- "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present? -------- Correct Answer -------- Amenorrhea 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? -------- Correct Answer -------- Escort the manic client to his or her room. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 21 / 4 A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed? -------- Correct Answer -------- "I know that I won't become depressed again." The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply. -------- Correct Answer -------- Outlandish behaviors Purposeless arousal and movement Grandiose delusions of being King Arthur Incessant talking that includes sexual innuendos Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply. -------- Correct Answer -------- Speak slowly. Use simple statements. Provide the client with high-calorie beverages. 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? -------- Correct Answer -------- Improvement A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client? - ------- Correct Answer -------- The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? -------- Correct Answer -------- A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? -------- Correct Answer -------- The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take? -------- Correct Answer -------- 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? -------- Correct Answer -------- The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? -------- Correct Answer -------- The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply. -------- Correct Answer -------- Oblivious to surroundings Unable to focus on anything Engaging in purposeless activity (walking around aimlessly) Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 22 / 4 Showing unproductive relief behavior (stomping, wringing hands, dropping things) The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? -------- Correct Answer ------ -- The false belief that one is being singled out for harm by others 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? -------- Correct Answer -------- "You're feeling angry that your family continues to hope for you to be 'cured'?" 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? -------- Correct Answer -------- "You don't think you can ever do anything right?" A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply. -------- Correct Answer -------- Severe suicidal tendencies Extremely unstable medical and psychiatric conditions Desire for punishment of client or convenience of staff Delirium or dementia leading to inability to tolerate decreased stimulation Severe drug reactions or overdoses or need for close monitoring of drug dosages 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? -------- Correct Answer -------- "I cannot discuss any client situation with you." 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? -------- Correct Answer -------- The client verbalizes stages of grief and plans to attend a community grief group. 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? -------- Correct Answer -------- Tell the client that the primary health care provider will be contacted regarding discharge. A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment? -------- Correct Answer -------- 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? -------- Correct Answer -------- Accept the client as a person and make the client feel safe. Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 25 / 4 ting limits on the client's behavior Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action. 4. The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? 1. Members should be of the same gender. 2. The group will decide the focus of the sessions. 3. The group should be limited to no more than 10 members. 4. The focus of the group will determine when the group will meet.: 3.The group should be limited to no more than 10 members. The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true. 5. The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1. "I am your friend." 2. "Our relationship is a therapeutic and helping one." 3. "I can't be your friend. I'm the nurse, and you're the client." 4. "You have plenty of friends.You don't need me to be your friend, too.": 2."Our relationship is a therapeutic and helping one." Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship. 6. A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 26 / 4 likely start to see improvement in approximately what time frame? 1.1 week after the 3rd treatment session 2.3 weeks after the treatment sessions begin 3.Midway between the 2nd and 3rd treatment session 4.8 weeks after the treatment sessions are completed: 1.1 week after the 3rd treatment session Health care providers generally administer electroconvulsive therapy (ECT) treat- ments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. The remaining options are incorrect. 7. During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia? 1.Refusing to eat and excessive exercising 2.Eating only vegetables and fruits and fasting 3. Hoarding of food and difficulty controlling food intake 4. Eating a lot of food in a short period of time and misuse of laxatives: 4.Eating a lot of food in a short period of time and misuse of laxatives Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem. 8. A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive: 1.Avoidant The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-com- Mental Health NCLEX-RN Exam New Latest Version Updated 2023-2024 with All Questions from Actual Past Exam and 100% Correct Answers 27 / 4 pulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work. 9. The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? 1. Coffee, tea, and soda consumption should be limited. 2. If the client is compliant, the relapse of symptoms will never occur. 3.Psy- chotropic medications may cause mild cardiovascular symptoms. 4.Most schizophrenic clients are able to taper off their medications eventual- ly.: 1.Coffee, tea, and soda consumption should be limited. Caffeine can inhibit the action of psychotropic medications commonly prescribed for schizophrenia. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is a strong factor in minimizing the reoccurrence of relapses, relapse could occur. Cardiovascular symptoms are not typical side effects of psychotropic medications. 10. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1."You need to stop that behavior now." 2."You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior.": 3."You seem restless; tell me what is happening." The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.