Psychiatric Mental Health Nursing NCLEX Questions and Answers Rated A (50 Questions)

Psychiatric Mental Health Nursing NCLEX Questions and Answers Rated A (50 Questions) 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." - ANS- C. "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 - ANS- D. 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 - ANS- B. 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 - ANS- B. 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 - ANS- C. 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 - ANS- C. 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 - ANS- A. 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. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, schedule during each shift D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy - ANS- D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy Rationale: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image. A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt B. Situational low self-esteem related to feelings of loss of control C. Risk for violence: Self-directed related to impulsive mutilating acts D. Risk for violence: Directed toward other related to verbal threats - ANS- C. Risk for violence: Self-directed related to impulsive mutilating acts Rationale: The predominant behavior characteristic of the client with borderline personal out disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your past job for missing too may days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?" - ANS- B. "You told me you got fired from your past job for missing too many days after taking drugs all night." Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussing should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior. A male client has approached the nurse asking for advice on how to derail with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy - ANS- B. Total abstinence Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies than can support the client in his efforts to abstain. A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting the neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hyper vigilance and talk of past violent acts - ANS- A. A rigid posture, restlessness, and glaring Rationale: Behavior clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentative ness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium) - ANS- D. clordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administer to treat seizures if they occur during the withdrawal. A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. Begin after 7 days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next 1-2 days D. Begin within 2-7 days - ANS- C. Begin anytime within the next 1-2 days Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1-2 days later. Delirium tremens may occur 2-4 days - even up to 7 days - after the last drink. A male client is being treated for alcoholism. After a family meetings, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join with organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous