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Mental Health Disorders: Saunders
NCLEX Review Questions and Correct
Answers/ Latest Update / Already
Graded
Aclient says to the nurse, "The federal guards were sent to kill me."
Which is the best response by the nurse to the client's concern?
1. "I don't believe this is true."
2. "The guards are not out to kill you."
3. "Do you feel afraid that people are trying to hurt you?"
4. "What makes you think the guards were sent to hurt you?"
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Ans: 3
Rationale: It is most therapeutic for the nurse to empathize with the client's
experience. The remaining options lack this connection with the client.
Disagreeing with delusions may make the client more defensive, and the
client may cling to the delusions even more. Encouraging discussion
regarding the delusion is inappropriate.
A client diagnosed with delirium becomes disor- iented and
confused at night. Which intervention should the nurse implement
initially?
1. Move the client next to the nurses' station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
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Ans: 2
Rationale: Provision ofaconsistentdailyroutineand alowstim- ulating
environment is important when a client is disoriented. Noise, including
radio and television, may add to the confusion and disorientation. Moving
the client next to the nurses'station may become necessary but is not the
initial action.
A client is admitted to the mental health unit with a diagnosis of
depression. The nurse should develop a plan of care for the client
that includes which intervention?
1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will pro- vide exercise
3. No socializing activities, until the client asks to participate in milieu
4. A structured program of activities in which the client can
participate
Mental Health Disorders: Saunders
NCLEX Review Questions and Correct
Answers/ Latest Update / Already
Graded
Aclient says to the nurse, "The federal guards were sent to kill me."
Which is the best response by the nurse to the client's concern?
1. "I don't believe this is true."
2. "The guards are not out to kill you."
3. "Do you feel afraid that people are trying to hurt you?"
4. "What makes you think the guards were sent to hurt you?"
,2 | Page
Ans: 3
Rationale: It is most therapeutic for the nurse to empathize with the client's
experience. The remaining options lack this connection with the client.
Disagreeing with delusions may make the client more defensive, and the
client may cling to the delusions even more. Encouraging discussion
regarding the delusion is inappropriate.
A client diagnosed with delirium becomes disor- iented and
confused at night. Which intervention should the nurse implement
initially?
1. Move the client next to the nurses' station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
, 3 | Page
Ans: 2
Rationale: Provision ofaconsistentdailyroutineand alowstim- ulating
environment is important when a client is disoriented. Noise, including
radio and television, may add to the confusion and disorientation. Moving
the client next to the nurses'station may become necessary but is not the
initial action.
A client is admitted to the mental health unit with a diagnosis of
depression. The nurse should develop a plan of care for the client
that includes which intervention?
1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will pro- vide exercise
3. No socializing activities, until the client asks to participate in milieu
4. A structured program of activities in which the client can
participate
