Mental Health Disorders: Saunders NCLEX Exam
Questions With Detailed Correct Answers
QUESTION>The nurse is caring for a client just admitted to the mental health unit and diagnosed with
catatonic stupor. The client is lying on the bed in a fetal posi- tion. Which is the most appropriate nursing
intervention?
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with occasional open-ended questions.
4. Take the client into the dayroom with other clients so that they can help watch them. - CORRECT
ANSWER~3
Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated
approaches. Com- munication with withdrawn clients requires much patience from the nurse.
Interventions include the establishment of interpersonal contact. The nurse facilitates communication
with the client by sitting in silence, asking open-ended ques- tions rather than direct questions, and
pausing to provide opportunities for the client to respond. While overstimulation is not appropriate,
there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other
clients.
QUESTION>The nurse is caring for a client diagnosed with para- noid personality disorder who is
experiencing dis- turbed thought processes. In formulating a nursing plan of care, which best
intervention should the nurse include?
1. Increase socialization of the client with peers.
2. Avoid using a whisper voice in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes. -
CORRECT ANSWER~2
Rationale: Disturbed thought process related to paranoid per- sonality disorder is the client's problem,
and the plan of care must address this problem. The client is distrustful and suspi- cious of others. The
members of the health care team need to establish a rapport and trust with the client. Laughing or whis-
, pering in front of the client would be counterproductive. The remaining options ask the client to trust on
a multitude of levels. These options are actions that are too intrusive for a cli- ent with this disorder.
QUESTION>The nurse is planning activities for a client diag- nosed with bipolar disorder with aggressive
social behavior. Which activity would be most appropri- ate for this client?
1. Chess
2. Writing
3. Pingpong
4. Basketball - CORRECT ANSWER~2
Rationale: Solitary activities that require a short attention span with mild physical exertion are the most
appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with
staff, and finger painting are activities that minimize stimuli and provide a constructive release for
tension. The remaining options have a competitive element to them and should be avoided because they
can stimulate aggression and increase psychomotor activity.
QUESTION >A client 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?" - CORRECT ANSWER~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.
QUESTION>A client diagnosed with delirium becomes disor- iented and confused at night. Which
intervention should the nurse implement initially?
Questions With Detailed Correct Answers
QUESTION>The nurse is caring for a client just admitted to the mental health unit and diagnosed with
catatonic stupor. The client is lying on the bed in a fetal posi- tion. Which is the most appropriate nursing
intervention?
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with occasional open-ended questions.
4. Take the client into the dayroom with other clients so that they can help watch them. - CORRECT
ANSWER~3
Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated
approaches. Com- munication with withdrawn clients requires much patience from the nurse.
Interventions include the establishment of interpersonal contact. The nurse facilitates communication
with the client by sitting in silence, asking open-ended ques- tions rather than direct questions, and
pausing to provide opportunities for the client to respond. While overstimulation is not appropriate,
there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other
clients.
QUESTION>The nurse is caring for a client diagnosed with para- noid personality disorder who is
experiencing dis- turbed thought processes. In formulating a nursing plan of care, which best
intervention should the nurse include?
1. Increase socialization of the client with peers.
2. Avoid using a whisper voice in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes. -
CORRECT ANSWER~2
Rationale: Disturbed thought process related to paranoid per- sonality disorder is the client's problem,
and the plan of care must address this problem. The client is distrustful and suspi- cious of others. The
members of the health care team need to establish a rapport and trust with the client. Laughing or whis-
, pering in front of the client would be counterproductive. The remaining options ask the client to trust on
a multitude of levels. These options are actions that are too intrusive for a cli- ent with this disorder.
QUESTION>The nurse is planning activities for a client diag- nosed with bipolar disorder with aggressive
social behavior. Which activity would be most appropri- ate for this client?
1. Chess
2. Writing
3. Pingpong
4. Basketball - CORRECT ANSWER~2
Rationale: Solitary activities that require a short attention span with mild physical exertion are the most
appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with
staff, and finger painting are activities that minimize stimuli and provide a constructive release for
tension. The remaining options have a competitive element to them and should be avoided because they
can stimulate aggression and increase psychomotor activity.
QUESTION >A client 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?" - CORRECT ANSWER~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.
QUESTION>A client diagnosed with delirium becomes disor- iented and confused at night. Which
intervention should the nurse implement initially?
