Mental Health nclex Exam Questions
With Correct Answers
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.
| | | | | | |
,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.
| |
With Correct Answers
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.
| | | | | | |
,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.
| |
