NURSING 144 |Psychiatric Mental Health
Nursing NCLEX Review Questions|
(Samuel Merritt University) 100% Verified
A 16-year-old girl is admitted for her first psychotic break. Her parents feel
very guilty. What is your best nursing response?
A. No one really knows the cause of schizophrenia. It is not your fault and is
not due to anything you did in the past. It is important to understand this, to
support your daughter, and to find support for yourselves.
B. Does anyone in your family have schizophrenia, as this disease is known to
be genetic?
C. You may feel bad now, but there are so many other bad things out there,
such as cancer and paralysis.
D. Let me share with you some websites to help you deal with your guilt. -
------------ANS: A. No one really knows the cause of schizophrenia. It is not
your fault and is not due to anything you did in the past. It is important to
understand this, to support your daughter, and to find support for yourselves.
Reason: Schizophrenia has a multifocal origin and its cause may include a
genetic component. Support is needed for both patients and caregivers.
A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet
exhibits sudden, excessive motor activity with repetitive sit-ups. What is this
behavior called?
A. Delusional.
B. Hallucinogenic.
C. Paranoid.
D. Catatonic. - ------------ANS: D. Catatonic.
Reason: Catatonic schizophrenia occurs suddenly and includes motor
immobility or excessive motor activity.
A 22-year-old female is admitted to the unit following a suicide attempt. She
has a 2-week history of depression as well as a history of abusing multiple
substances and anorexia nervosa. What is your first nursing priority?
A. Socialization.
B. Contracting for eating behavior.
,C. Safety.
D. Administering the Beck depression scale. - ------------ANS: C. Safety.
Reason: Safety is the major principle underlying psychiatric nursing.
A 22-year-old female was admitted to the mental health unit with major
depression and suicidal ideation. She has a history of cutting her wrists
intermittently throughout the last 2 years. On days 1 and 2, the patient stays in
her room and eats only 20% of her meals. On day 3, she eats 80% of her
meals and is talking to others in group. The nurse should consider that the
patient is
A. Showing improvement.
B. Highly suicidal.
C. Exhibiting mood swings.
D. In need of electroshock therapy. - ------------ANS: A. Showing improvement.
Reason: The patient improvement is based on increased socialization and
increased appetite.
A 35-year-old male patient has been brought to your hospital unit after making
a suicide attempt at his workplace. Which of the following interventions can
you legally implement?
A. Call the patient's girlfriend and inform her of his admission and visiting
hours.
B. Physically search the patient for weapons and harmful materials.
C. Call the patient's boss at work and report him as in need of extended
medical leave.
D. Place the patient in four-point restraints and begin an IV for sedation. -
------------ANS: B. Physically search the patient for weapons and harmful
materials.
Reason: A suicide attempt is a serious and self-destructive behavior that
demands searching for weapons and harmful materials to increase safety.
A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist
after receiving a call by her son. According to the son, since his father's death
7 months ago, his mother has lost 30 pounds and can't sleep. During her initial
visit, the patient states, 'My husband talks to me in his visits, but his words
make no sense to me. I don't understand what he wants me to do.' What is an
appropriate nursing diagnosis?
, A. Ineffective denial.
B. Bipolar mood disorder.
C. Hyper-religiosity.
D. Grieving. - ------------ANS: D. Grieving.
Reason: Grieving may be characterized by weight loss, sleep disturbances,
and messages from beyond.
A hypomanic patient tells you that she has been 'picking up energy from my
car engine and car CD player' while driving and has received five speeding
tickets in the past 6 months. What would be one effective intervention to avoid
fast driving?
A. Make a contract not to drive more than 55 miles per hour and drive with the
CD played turned off.
B. Call the local police and alert them to the patient's car license plate number
and the make and model of her car.
C. Ask the patient to "hand over the keys" to you, and tell her that now she
must use a cab or other public transportation until your next session.
D. Share with the patient that she cannot drink and drive. - ------------ANS: A.
Make a contract not to drive more than 55 miles per hour and drive with the
CD played turned off.
Reason: Contracts can see a patient through period of hypomanic agitation.
A patient has been admitted to your unit with a drug overdose, and you need
to assess for acidosis and hypoxemia. Which test should you perform?
A. Complete blood count (CBC).
B. Serum electrolytes.
C. Partial thromboplastin time (PTT).
D. Arterial blood gases (ABG). - ------------ANS: D. Arterial blood gases (ABG).
Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].
A patient who is psychotic has a formed bowel movement on the floor of his
room. How should you clean up this excrement?
A. Use a thick diaper or pad.
B. Wear gloves and use some paper towels or toilet paper.
C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach
solution.
Nursing NCLEX Review Questions|
(Samuel Merritt University) 100% Verified
A 16-year-old girl is admitted for her first psychotic break. Her parents feel
very guilty. What is your best nursing response?
A. No one really knows the cause of schizophrenia. It is not your fault and is
not due to anything you did in the past. It is important to understand this, to
support your daughter, and to find support for yourselves.
B. Does anyone in your family have schizophrenia, as this disease is known to
be genetic?
C. You may feel bad now, but there are so many other bad things out there,
such as cancer and paralysis.
D. Let me share with you some websites to help you deal with your guilt. -
------------ANS: A. No one really knows the cause of schizophrenia. It is not
your fault and is not due to anything you did in the past. It is important to
understand this, to support your daughter, and to find support for yourselves.
Reason: Schizophrenia has a multifocal origin and its cause may include a
genetic component. Support is needed for both patients and caregivers.
A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet
exhibits sudden, excessive motor activity with repetitive sit-ups. What is this
behavior called?
A. Delusional.
B. Hallucinogenic.
C. Paranoid.
D. Catatonic. - ------------ANS: D. Catatonic.
Reason: Catatonic schizophrenia occurs suddenly and includes motor
immobility or excessive motor activity.
A 22-year-old female is admitted to the unit following a suicide attempt. She
has a 2-week history of depression as well as a history of abusing multiple
substances and anorexia nervosa. What is your first nursing priority?
A. Socialization.
B. Contracting for eating behavior.
,C. Safety.
D. Administering the Beck depression scale. - ------------ANS: C. Safety.
Reason: Safety is the major principle underlying psychiatric nursing.
A 22-year-old female was admitted to the mental health unit with major
depression and suicidal ideation. She has a history of cutting her wrists
intermittently throughout the last 2 years. On days 1 and 2, the patient stays in
her room and eats only 20% of her meals. On day 3, she eats 80% of her
meals and is talking to others in group. The nurse should consider that the
patient is
A. Showing improvement.
B. Highly suicidal.
C. Exhibiting mood swings.
D. In need of electroshock therapy. - ------------ANS: A. Showing improvement.
Reason: The patient improvement is based on increased socialization and
increased appetite.
A 35-year-old male patient has been brought to your hospital unit after making
a suicide attempt at his workplace. Which of the following interventions can
you legally implement?
A. Call the patient's girlfriend and inform her of his admission and visiting
hours.
B. Physically search the patient for weapons and harmful materials.
C. Call the patient's boss at work and report him as in need of extended
medical leave.
D. Place the patient in four-point restraints and begin an IV for sedation. -
------------ANS: B. Physically search the patient for weapons and harmful
materials.
Reason: A suicide attempt is a serious and self-destructive behavior that
demands searching for weapons and harmful materials to increase safety.
A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist
after receiving a call by her son. According to the son, since his father's death
7 months ago, his mother has lost 30 pounds and can't sleep. During her initial
visit, the patient states, 'My husband talks to me in his visits, but his words
make no sense to me. I don't understand what he wants me to do.' What is an
appropriate nursing diagnosis?
, A. Ineffective denial.
B. Bipolar mood disorder.
C. Hyper-religiosity.
D. Grieving. - ------------ANS: D. Grieving.
Reason: Grieving may be characterized by weight loss, sleep disturbances,
and messages from beyond.
A hypomanic patient tells you that she has been 'picking up energy from my
car engine and car CD player' while driving and has received five speeding
tickets in the past 6 months. What would be one effective intervention to avoid
fast driving?
A. Make a contract not to drive more than 55 miles per hour and drive with the
CD played turned off.
B. Call the local police and alert them to the patient's car license plate number
and the make and model of her car.
C. Ask the patient to "hand over the keys" to you, and tell her that now she
must use a cab or other public transportation until your next session.
D. Share with the patient that she cannot drink and drive. - ------------ANS: A.
Make a contract not to drive more than 55 miles per hour and drive with the
CD played turned off.
Reason: Contracts can see a patient through period of hypomanic agitation.
A patient has been admitted to your unit with a drug overdose, and you need
to assess for acidosis and hypoxemia. Which test should you perform?
A. Complete blood count (CBC).
B. Serum electrolytes.
C. Partial thromboplastin time (PTT).
D. Arterial blood gases (ABG). - ------------ANS: D. Arterial blood gases (ABG).
Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].
A patient who is psychotic has a formed bowel movement on the floor of his
room. How should you clean up this excrement?
A. Use a thick diaper or pad.
B. Wear gloves and use some paper towels or toilet paper.
C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach
solution.
