Mental health nclex questions and
answers 2024\2025 A+ Grade
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.
Although lack of support system is a risk factor for elder abuse, socioeconomic status alone does not
correlate with an increased risk.
Frequent ER visits do not increase risk of elder abuse, but could be the outcome of abuse.
When providing care for a client who reports to the emergency department immediately after a sexual
assault, which nursing actions are appropriate?
Select all that apply.
Offer a support person or crisis advocate
Provide appropriate care for injuries
Make the client sign the exam consent form
, Contact law enforcement
Determine whether the sexual activity was consensual
- correct answer Offer a support person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
• The nurse should offer an advocate from a local crisis center to provide support, reassurance and
resources. The nurse should let the client know that she or he has the right to have a friend or family
member present
•The nurse should also provide care for and document any injuries and notify local law enforcement.
•Law enforcement should be immediately available in case the client chooses to file a report or to
transport the evidence collection kit. Some states mandate reporting any sexual assault, while other
states only mandate reporting sexual assault for children or elders.
•In the emergency room, the nurse is responsible for collecting evidence as well.
• A consent must be obtained from the client in order to perform a sexual assault exam. The client
should not be forced or pressured to consent to the exam, and adult clients may decline to make a
report to law enforcement.
• After emotional support is provided, the nurse will assist with exam and collect specimens. The nurse
should document all objective evidence, including the client's physical condition and statements.
answers 2024\2025 A+ Grade
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.
Although lack of support system is a risk factor for elder abuse, socioeconomic status alone does not
correlate with an increased risk.
Frequent ER visits do not increase risk of elder abuse, but could be the outcome of abuse.
When providing care for a client who reports to the emergency department immediately after a sexual
assault, which nursing actions are appropriate?
Select all that apply.
Offer a support person or crisis advocate
Provide appropriate care for injuries
Make the client sign the exam consent form
, Contact law enforcement
Determine whether the sexual activity was consensual
- correct answer Offer a support person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
• The nurse should offer an advocate from a local crisis center to provide support, reassurance and
resources. The nurse should let the client know that she or he has the right to have a friend or family
member present
•The nurse should also provide care for and document any injuries and notify local law enforcement.
•Law enforcement should be immediately available in case the client chooses to file a report or to
transport the evidence collection kit. Some states mandate reporting any sexual assault, while other
states only mandate reporting sexual assault for children or elders.
•In the emergency room, the nurse is responsible for collecting evidence as well.
• A consent must be obtained from the client in order to perform a sexual assault exam. The client
should not be forced or pressured to consent to the exam, and adult clients may decline to make a
report to law enforcement.
• After emotional support is provided, the nurse will assist with exam and collect specimens. The nurse
should document all objective evidence, including the client's physical condition and statements.
