MENTAL HEALTH NCLEX QUESTIONS
& DETAILED CORRECT ANSWERS
100%
The home care nurse assesses an older adult client living with adult children. The client is thin
and frail, with bruising on the upper arms and back. Which circumstances alert the nurse to an
increased risk of abuse?
Select all that apply.
Lower socioeconomic status of the older adult client's family.
The elderly client has a psychiatric diagnosis, such as dementia or depression.
The abuse of alcohol by the older adult client and/or a family member in the home.
Physical or cognitive impairment making the client dependent on others for activities of daily
living.
Frequent emergency room visits for falls or unexplained illnesses. - correct answer ✔✔The
elderly client has a psychiatric diagnosis, such as dementia or depression.
- The presence of any psychiatric diagnosis increases risk of elder abuse.
The abuse of alcohol by the older adult client and/or a family member in the home.
- Alcohol abuse increases risk of elder abuse.
,Physical or cognitive impairment making the client dependent on others for activities of daily
living.
- Financial or physical dependence on others increases the risk of elder abuse, in part because
of the strain this dependency puts on the family. The vulnerable older adult may also feel
unable to speak out against any mistreatment they receive, beacuase they have nowhere else to
go.
Explanation
Elder neglect and abuse affects an estimated 2-10% of adults, but is known to be under-
reported. Nurses are mandated to report known or suspected elder abuse to Adult Protective
Services or to law enforcement. Signs of possible neglect or abuse include bruising, bilateral
injuries, oversedation, weight loss, poor hygiene, depression, agitation, or withdrawal. Older
adult clients are often unable or scared to report abuse. Abusers have various motivations
including trying to get their "fair share," having a history of using physical means to solve
problems, and other social, biomedical, relationship, and environmental characteristics.
Although lack of support system is a risk factor for elder abuse, socioeconomic status alone
does not correlate with an increased risk.
Frequent ER visits do not increase risk of elder abuse, but could be the outcome of abuse.
A male patient in the psychiatric unit experiencing a state of mania is walking the halls
completely naked. How should the nurse respond initially? (select all that apply)
Quietly escort the patient to his room.
Tell the patient he will be secluded if he does not get dressed.
,Ask the other patients to go to their rooms.
Confront the patient and insist he get dressed.
Encourage the patient to get dressed.
Withhold family visits due to inappropriate behavior. - correct answer ✔✔Quietly escort the
patient to his room.
Encourage the patient to get dressed.
Explanation
• The nurse should take control of the situation without causing the patient more anxiety. Walk
the patient to his room and encourage him to dress there.
• A manic patient often lacks good judgement and has poor impulse control, but may respond
well to non-threatening encouragement.
• A manic patient is more receptive to non-threatening direction than confrontation, and
walking with the patient to his room and encouraging him to get dressed so that he can do
something else he enjoys will get better results than issuing an order.
• Confronting the patient or threatening the patient with seclusion or restraint will often
escalate the situation or lead to resistance.
• Asking the other patients to return to their rooms is not appropriate.
, • Withholding visitation is not an appropriate response.
When providing care for a client who reports to the emergency department immediately after a
sexual assault, which nursing actions are appropriate?
Select all that apply.
Offer a support person or crisis advocate
Provide appropriate care for injuries
Make the client sign the exam consent form
Contact law enforcement
Determine whether the sexual activity was consensual - correct answer ✔✔Offer a support
person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
• The nurse should offer an advocate from a local crisis center to provide support, reassurance
and resources. The nurse should let the client know that she or he has the right to have a friend
or family member present
•The nurse should also provide care for and document any injuries and notify local law
enforcement.
& DETAILED CORRECT ANSWERS
100%
The home care nurse assesses an older adult client living with adult children. The client is thin
and frail, with bruising on the upper arms and back. Which circumstances alert the nurse to an
increased risk of abuse?
Select all that apply.
Lower socioeconomic status of the older adult client's family.
The elderly client has a psychiatric diagnosis, such as dementia or depression.
The abuse of alcohol by the older adult client and/or a family member in the home.
Physical or cognitive impairment making the client dependent on others for activities of daily
living.
Frequent emergency room visits for falls or unexplained illnesses. - correct answer ✔✔The
elderly client has a psychiatric diagnosis, such as dementia or depression.
- The presence of any psychiatric diagnosis increases risk of elder abuse.
The abuse of alcohol by the older adult client and/or a family member in the home.
- Alcohol abuse increases risk of elder abuse.
,Physical or cognitive impairment making the client dependent on others for activities of daily
living.
- Financial or physical dependence on others increases the risk of elder abuse, in part because
of the strain this dependency puts on the family. The vulnerable older adult may also feel
unable to speak out against any mistreatment they receive, beacuase they have nowhere else to
go.
Explanation
Elder neglect and abuse affects an estimated 2-10% of adults, but is known to be under-
reported. Nurses are mandated to report known or suspected elder abuse to Adult Protective
Services or to law enforcement. Signs of possible neglect or abuse include bruising, bilateral
injuries, oversedation, weight loss, poor hygiene, depression, agitation, or withdrawal. Older
adult clients are often unable or scared to report abuse. Abusers have various motivations
including trying to get their "fair share," having a history of using physical means to solve
problems, and other social, biomedical, relationship, and environmental characteristics.
Although lack of support system is a risk factor for elder abuse, socioeconomic status alone
does not correlate with an increased risk.
Frequent ER visits do not increase risk of elder abuse, but could be the outcome of abuse.
A male patient in the psychiatric unit experiencing a state of mania is walking the halls
completely naked. How should the nurse respond initially? (select all that apply)
Quietly escort the patient to his room.
Tell the patient he will be secluded if he does not get dressed.
,Ask the other patients to go to their rooms.
Confront the patient and insist he get dressed.
Encourage the patient to get dressed.
Withhold family visits due to inappropriate behavior. - correct answer ✔✔Quietly escort the
patient to his room.
Encourage the patient to get dressed.
Explanation
• The nurse should take control of the situation without causing the patient more anxiety. Walk
the patient to his room and encourage him to dress there.
• A manic patient often lacks good judgement and has poor impulse control, but may respond
well to non-threatening encouragement.
• A manic patient is more receptive to non-threatening direction than confrontation, and
walking with the patient to his room and encouraging him to get dressed so that he can do
something else he enjoys will get better results than issuing an order.
• Confronting the patient or threatening the patient with seclusion or restraint will often
escalate the situation or lead to resistance.
• Asking the other patients to return to their rooms is not appropriate.
, • Withholding visitation is not an appropriate response.
When providing care for a client who reports to the emergency department immediately after a
sexual assault, which nursing actions are appropriate?
Select all that apply.
Offer a support person or crisis advocate
Provide appropriate care for injuries
Make the client sign the exam consent form
Contact law enforcement
Determine whether the sexual activity was consensual - correct answer ✔✔Offer a support
person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
• The nurse should offer an advocate from a local crisis center to provide support, reassurance
and resources. The nurse should let the client know that she or he has the right to have a friend
or family member present
•The nurse should also provide care for and document any injuries and notify local law
enforcement.
