Psychiatric Mental Health Nursing NCLEX 50 Questions and Answers 2025
A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's
weight loss and constant dieting. The nurse conducts health history interview. Which of the following
comments indicates that the client may be suffering from anorexia nervosa?
A. "I like the way I look. I just need to keep my weight down because I'nm a cheerleader."
B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends."
C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."
D. "I do diet around my periods; otherwise, I just get so bloated." - ANSC. "I just can't seem to get down to the
weight I want to be. I'm so fat compared to other girls."
Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a
"desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor
self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be
distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror. Proffering
fast food over health food is common in this age-group. Because of the absence of body fat necessary for
proper hormone production, amenorrhea is common in this client with anorexia nervosa.
A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look
so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and
feelings?
A. Avoid discussing the client's perceptions and feelings
B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client's weight and attractiveness - ANSD. Provide
objective data and feedback regarding the client's weight and attractiveness
Rationale: By focusing on reality, this strategy may help the client develop a more realistic body image and gain
self-esteem. Option A is inappropriate because discussing the client's perceptions and feelings wouldn't help
her identify, accept, and work through them. Focusing discussions on food and weight would the client
attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic
cultural standards wouldn't help the client establish more realistic weight goals.
A 25-year-old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the
following goals is a priority?
A. The client will commit to a drug-free lifestyle
,B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strengths - ANSB. The client will work with the nurse to remain
safe
Rationale: The priority goal in alcohol withdrawal is maintaining the client' safety. Committing to a drug-free
lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensure the client's
safety is the nurse's top priority.
A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that
this exacerbation of anorexia nervosa results from the client's effort to:
A. Manipulate her husband
B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother's expectations - ANSB. Gain control of one part of her life
Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over
the only part of her life she feels she can control. This eating disorder doesn't represent an attempt to
manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families
that emphasizes achievement). The client isn't attempting to commit suicide through starvation; rather, by
refusing to eat, she is expressing feelings or despair, worthlessness,s and hopelessness.
A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best nursing
intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
C. Providing a quiet environment and administering medications as needed and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes - ANSC. Providing a quiet
environment and administering medications as needed and prescribed
Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce
stimulation and administering prescribed central nervous system depressants in dosages that control symptom
without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses
a danger to himself or others. Also, restrains may increase agitation and make the client feel trapped and
helpless when hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes
would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure
, every 2 hours.
A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's
physical health, the nurse should plan to:
A. Severely restrict the client's physical activities
B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolytes levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake - ANSC. Monitor vital signs, serum
electrolyte levels, and acid-base balance
Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may
die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte levels, and acid-base
balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after
breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with
attention for not eating and reinforce the control issues that are central to the underlying psychological
problem; also, the client may record food and fluid intake inaccurately.
A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the
nurse should:
A. Check on the client frequently at irregular intervals throughout the night
B. Assure the client that the nurse will hold in confidence anything the client says
C. Repeatedly discuss previous suicide attempts with the client
D. Disregard decreased communication by the client because this is common in suicidal clients - ANSA. Check
on the client frequently at irregular intervals throughout the night
Rationale: Checking the client frequently but at irregular intervals prevents the client from predicting when
observation will take place and altering behavior in a misleading way at these times. Option B may encourage
the client to try to manipulate the nurse's or seek attention for having a secret suicide plan. Option C may
reinforce a suicidal idea. Decreased communication is a sign of withdrawal that may indicate the client has
decided to commit suicide; the nurse shouldn't disregard it.
A female client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals
that the client is 5'8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body
image, which intervention should the nurse include in the plan of care?
A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's
weight loss and constant dieting. The nurse conducts health history interview. Which of the following
comments indicates that the client may be suffering from anorexia nervosa?
A. "I like the way I look. I just need to keep my weight down because I'nm a cheerleader."
B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends."
C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."
D. "I do diet around my periods; otherwise, I just get so bloated." - ANSC. "I just can't seem to get down to the
weight I want to be. I'm so fat compared to other girls."
Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a
"desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor
self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be
distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror. Proffering
fast food over health food is common in this age-group. Because of the absence of body fat necessary for
proper hormone production, amenorrhea is common in this client with anorexia nervosa.
A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look
so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and
feelings?
A. Avoid discussing the client's perceptions and feelings
B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client's weight and attractiveness - ANSD. Provide
objective data and feedback regarding the client's weight and attractiveness
Rationale: By focusing on reality, this strategy may help the client develop a more realistic body image and gain
self-esteem. Option A is inappropriate because discussing the client's perceptions and feelings wouldn't help
her identify, accept, and work through them. Focusing discussions on food and weight would the client
attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic
cultural standards wouldn't help the client establish more realistic weight goals.
A 25-year-old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the
following goals is a priority?
A. The client will commit to a drug-free lifestyle
,B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strengths - ANSB. The client will work with the nurse to remain
safe
Rationale: The priority goal in alcohol withdrawal is maintaining the client' safety. Committing to a drug-free
lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensure the client's
safety is the nurse's top priority.
A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that
this exacerbation of anorexia nervosa results from the client's effort to:
A. Manipulate her husband
B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother's expectations - ANSB. Gain control of one part of her life
Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over
the only part of her life she feels she can control. This eating disorder doesn't represent an attempt to
manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families
that emphasizes achievement). The client isn't attempting to commit suicide through starvation; rather, by
refusing to eat, she is expressing feelings or despair, worthlessness,s and hopelessness.
A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best nursing
intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
C. Providing a quiet environment and administering medications as needed and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes - ANSC. Providing a quiet
environment and administering medications as needed and prescribed
Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce
stimulation and administering prescribed central nervous system depressants in dosages that control symptom
without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses
a danger to himself or others. Also, restrains may increase agitation and make the client feel trapped and
helpless when hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes
would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure
, every 2 hours.
A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's
physical health, the nurse should plan to:
A. Severely restrict the client's physical activities
B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolytes levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake - ANSC. Monitor vital signs, serum
electrolyte levels, and acid-base balance
Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may
die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte levels, and acid-base
balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after
breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with
attention for not eating and reinforce the control issues that are central to the underlying psychological
problem; also, the client may record food and fluid intake inaccurately.
A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the
nurse should:
A. Check on the client frequently at irregular intervals throughout the night
B. Assure the client that the nurse will hold in confidence anything the client says
C. Repeatedly discuss previous suicide attempts with the client
D. Disregard decreased communication by the client because this is common in suicidal clients - ANSA. Check
on the client frequently at irregular intervals throughout the night
Rationale: Checking the client frequently but at irregular intervals prevents the client from predicting when
observation will take place and altering behavior in a misleading way at these times. Option B may encourage
the client to try to manipulate the nurse's or seek attention for having a secret suicide plan. Option C may
reinforce a suicidal idea. Decreased communication is a sign of withdrawal that may indicate the client has
decided to commit suicide; the nurse shouldn't disregard it.
A female client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals
that the client is 5'8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body
image, which intervention should the nurse include in the plan of care?
