MENTAL HEALTH EXAM 2 NCLEX {QUESTIONS AND ANSWERS| 100%
CORRECT.
a client with delirium becomes agitated and confused at night. The best initial
intervention by the nurse is to:
1.move the client next to the nurse's station
2.use a night light and turn off the television
3.keep up 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 a night light and
turn off the television
a nurse is collecting data on a client who is actively hallucinating. WHich nursing
statement would be therapeutic at this time?
1."I know you feel they are out to get you, but its not true"
2."I can hear the voice and she wants you to come to dinner"
3."sometimes people hear things or voices others can't hear"
4."I talked to the voices you're hearing and they won't hurt you now" - 3."sometimes
people hear things or voices others can't hear"
a nurse is caring for a client with a diagnosis of depression. the nurse monitors for signs
of constipation and urinary retention, knowing that these problems are likely caused by:
1.poor dietary choices
2.lack of exercise and poor diet
3.inadequate dietary intake and dehydration
4.psychomotor retardation and side effects of medication - 4.psychomotor retardation
and side effects of medication
a client is admitted to the in-patient unit and is being considered for electroconvulsive
therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the
client's mother begins to cry and states, "my child's brain will be destroyed. How can the
doctor do this?" the nurse makes which therapeutic response?
1."it sounds as though you need to speak to the psychiatrist."
2."perhaps you'd like to see the ECT room and speak to the staff"
3.your child has decided to have this treatment. you should be supportive of the
decision"
4.it sounds as though you have some concerns about the ECT procedure. Why don't we
sit down together and discuss any concerns you may have?" - 4.it sounds as though
, you have some concerns about the ECT procedure. Why don't we sit down together and
discuss any concerns you may have?"
a client who is diagnosed with pedophilia and has been recently paroled as a sex
offender says "Im in treatment and I have served my time. Now this group has posters
of me all over the neighborhood telling about me with my picture on it" which of the
following is an appropriate response by the nurse?
1. "when children are hurt as you hurt them, people want you isolated"
2. "you're lucky it doesn't escalate into something pretty scary after your crime"
3."you understand that people fear for their children, but you're feeling unfairly treated?"
4."you seem angry, but you have committed serious crimes against several children, so
your neighbors are frightened?" - 3."you understand that people fear for their children,
but you're feeling unfairly treated?"
a 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 about
interventions for hallucinations and anxiety and determines that the client understands
the interventions when the client states:
1. "my medications won't make me anxious"
2. "i'll go to a support group and talk so that I won't hurt anyone."
3."I won't get anxious or hear things if I get enough sleep and eat well"
4."I can call my therapist when Im hallucinating so that I can talk about my feelings and
plans and not hurt anyone" - 4."I can call my therapist when Im hallucinating so that I
can talk about my feelings and plans and not hurt anyone"
a 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 affect is
belligerent. Based on these observations, the nurse's immediate priority of care is to:
1.Provide safety for the client and other clients on the unit
2.Provide the clients on the unit with a sense of comfort and safety
3. Assist the staff in caring for the client in a controlled environment
4.offer the client a less-stimulating area to calm down and gain control - 1.Provide
safety for the client and other clients on the unit
a nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the
bed, with the body pulled into a fetal position. the appropriate nursing intervention is
which of the following?
1.ask direct questions to encourage talking.
2.leave the client alone and intermittently check on him.
3.sit beside the client in silence and verbalize occasional open-ended questions.
4.take the client into the dayroom with other clients so they can help watch him - 3.sit
beside the client in silence and verbalize occasional open-ended questions.
CORRECT.
a client with delirium becomes agitated and confused at night. The best initial
intervention by the nurse is to:
1.move the client next to the nurse's station
2.use a night light and turn off the television
3.keep up 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 a night light and
turn off the television
a nurse is collecting data on a client who is actively hallucinating. WHich nursing
statement would be therapeutic at this time?
1."I know you feel they are out to get you, but its not true"
2."I can hear the voice and she wants you to come to dinner"
3."sometimes people hear things or voices others can't hear"
4."I talked to the voices you're hearing and they won't hurt you now" - 3."sometimes
people hear things or voices others can't hear"
a nurse is caring for a client with a diagnosis of depression. the nurse monitors for signs
of constipation and urinary retention, knowing that these problems are likely caused by:
1.poor dietary choices
2.lack of exercise and poor diet
3.inadequate dietary intake and dehydration
4.psychomotor retardation and side effects of medication - 4.psychomotor retardation
and side effects of medication
a client is admitted to the in-patient unit and is being considered for electroconvulsive
therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the
client's mother begins to cry and states, "my child's brain will be destroyed. How can the
doctor do this?" the nurse makes which therapeutic response?
1."it sounds as though you need to speak to the psychiatrist."
2."perhaps you'd like to see the ECT room and speak to the staff"
3.your child has decided to have this treatment. you should be supportive of the
decision"
4.it sounds as though you have some concerns about the ECT procedure. Why don't we
sit down together and discuss any concerns you may have?" - 4.it sounds as though
, you have some concerns about the ECT procedure. Why don't we sit down together and
discuss any concerns you may have?"
a client who is diagnosed with pedophilia and has been recently paroled as a sex
offender says "Im in treatment and I have served my time. Now this group has posters
of me all over the neighborhood telling about me with my picture on it" which of the
following is an appropriate response by the nurse?
1. "when children are hurt as you hurt them, people want you isolated"
2. "you're lucky it doesn't escalate into something pretty scary after your crime"
3."you understand that people fear for their children, but you're feeling unfairly treated?"
4."you seem angry, but you have committed serious crimes against several children, so
your neighbors are frightened?" - 3."you understand that people fear for their children,
but you're feeling unfairly treated?"
a 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 about
interventions for hallucinations and anxiety and determines that the client understands
the interventions when the client states:
1. "my medications won't make me anxious"
2. "i'll go to a support group and talk so that I won't hurt anyone."
3."I won't get anxious or hear things if I get enough sleep and eat well"
4."I can call my therapist when Im hallucinating so that I can talk about my feelings and
plans and not hurt anyone" - 4."I can call my therapist when Im hallucinating so that I
can talk about my feelings and plans and not hurt anyone"
a 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 affect is
belligerent. Based on these observations, the nurse's immediate priority of care is to:
1.Provide safety for the client and other clients on the unit
2.Provide the clients on the unit with a sense of comfort and safety
3. Assist the staff in caring for the client in a controlled environment
4.offer the client a less-stimulating area to calm down and gain control - 1.Provide
safety for the client and other clients on the unit
a nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the
bed, with the body pulled into a fetal position. the appropriate nursing intervention is
which of the following?
1.ask direct questions to encourage talking.
2.leave the client alone and intermittently check on him.
3.sit beside the client in silence and verbalize occasional open-ended questions.
4.take the client into the dayroom with other clients so they can help watch him - 3.sit
beside the client in silence and verbalize occasional open-ended questions.
