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Mental Health - N244 Questions and
Answers (Expert Solutions)
Q: Which data indicates to the nurse that a client may be experiencing ineffective
coping?, 🗹🗹: Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and
anxiety. In response to a death, ineffective coping is manifested by an extreme behavior
that in some instances may be harmful to the individual, physically, psychologically, or
both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as
part of the grieving process.
Q: Which client is most likely at risk to become a victim of elder abuse?, 🗹🗹: A 90-
year-old woman with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes
physical and psychological abuse, the misuse of property, and the violation of rights.
The typical abuse victim is a woman of advanced age with few social contacts and at
least one physical or mental impairment that limits her ability to perform activities of
daily living. In addition, the client usually lives alone or with the abuser and depends on
the abuser for care.
Q: Which data collection finding would indicate the possibility of the sexual abuse of a
child?, 🗹🗹: Swelling of the genitals
Q: A nurse is assigned to care for a client who is experiencing disturbed thought
processes. The nurse is told that the client believes that the food is being poisoned.
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Which communication technique does the nurse plan to use to encourage the client to
eat?, 🗹🗹: Open-ended questions and silence
Open-ended questions and silence are strategies used to encourage clients to discuss
their problem. Should encourage the client to identify the reasons for the behavior.
Q: A nurse is assigned to care for a client admitted to the hospital after sustaining an
injury from a house fire. The client attempted to save a neighbor involved in the fire but,
in spite of the client's efforts, the neighbor died. Which action would the nurse take to
enable the client to work through the meaning of the crisis?, 🗹🗹: Inquiring about
the client's feelings that may affect coping
The client must first deal with feelings and negative responses before the client is able
to work through the meaning of the crisis.
Q: A nurse is assisting with the data collection on a client admitted to the psychiatric
unit. The nurse reviews the data obtained and identifies which of the following as a
priority concern?, 🗹🗹: The client's report of suicidal thoughts
The client's thoughts are extremely important when verbalized. Suicidal thoughts are
the highest priority.
Q: Laboratory work is prescribed for a client who has been experiencing delusions.
When the laboratory technician approaches the client to obtain a specimen of the
client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The
nurse who is present at the time should respond by stating which of the following?,
🗹🗹: "Are you fearful and think that others may want to hurt you?"
Option 3 is the only option that recognizes the client's need. This response helps the
client focus on the emotion underlying the delusion but does not argue with it. If the
nurse attempts to change the client's mind, the delusion may, in fact, be even more
strongly held
Q: An intoxicated client is brought to the emergency department by local police. The
client is told that the health care provider (HCP) will be in to see the client in about 30
minutes. The client becomes very loud and offensive and wants to be seen by the HCP
immediately. The nurse assisting to care for the client would plan for which appropriate
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nursing intervention?, 🗹🗹: Offer to take the client to an examination room until he
or she can be treated.
Safety of the client, other clients, and staff is of prime concern. When dealing with an
impaired individual, trying to talk may be out of the question. Waiting to intervene
could cause the client to become even more agitated and a threat to others
Q: A client is admitted to a psychiatric unit for treatment of psychotic behavior. The
client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with
me! I don't belong here!" The nurse identifies this behavior as:, 🗹🗹: Denial
Denial is refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and
attributes them to other people, objects, or situations.
In regression, the client returns to an earlier, more comforting, although less mature
way of behaving.
Rationalization is justifying the unacceptable attributes about oneself.
Q: A client says to the nurse, "I'm going to die, and I wish my family would stop hoping
for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's
dying." The therapeutic response by the nurse is:, 🗹🗹: "You're feeling angry that
your family continues to hope for you to be 'cured'?"
Reflection is the therapeutic communication technique that redirects the client's
feelings back to validate what the client is saying.
Q: A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days
ago. On review of the client's record, the nurse notes that the admission was a voluntary
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admission. Based on this type of admission, the nurse would expect which of the
following?, 🗹🗹: The client will participate in the treatment plan.
Generally, voluntary admission is sought by the client or client's guardian. If the client
seeks voluntary admission, the most likely expectation is that the client will participate
in the treatment program.
Q: A licensed practical nurse (LPN) enters a client's room, and the client is demanding
release from the hospital. The LPN reviews the client's record and notes that the client
was admitted 2 days ago for treatment of an anxiety disorder, and that the admission
was a voluntary admission. The LPN reports the findings to the registered nurse (RN)
and expects that the RN will take which of the following actions?, 🗹🗹: Contact the
health care provider (HCP).
Generally, voluntary admission is sought by the client or client's guardian. Voluntary
clients have the right to demand and obtain release. The best nursing action is to
contact the HCP.
Q: A client is admitted to the psychiatric nursing unit. When collecting data from the
client, the nurse notes that the client was admitted on an involuntary status. Based on
this type of admission, the nurse likely expects that the client:, 🗹🗹: Presents a harm
to self
Involuntary admission is made without the client's consent. Involuntary admission is
necessary when a person is a danger to self or others or is in need of psychiatric
treatment or physical care
Q: Following a group therapy session, a client approaches the licensed practical nurse
(LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN
reports the findings to the registered nurse (RN) and expects that the RN will take
which of the following actions?, 🗹🗹: Get a written prescription from the health care
provider (HCP) and obtain an informed consent.
A client may request to be secluded or restrained. Federal laws require the consent of
the client, unless an emergency situation exists in which an immediate risk to the client
or others can be documented. The use of seclusion and restraint is permitted only on
Mental Health - N244 Questions and
Answers (Expert Solutions)
Q: Which data indicates to the nurse that a client may be experiencing ineffective
coping?, 🗹🗹: Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and
anxiety. In response to a death, ineffective coping is manifested by an extreme behavior
that in some instances may be harmful to the individual, physically, psychologically, or
both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as
part of the grieving process.
Q: Which client is most likely at risk to become a victim of elder abuse?, 🗹🗹: A 90-
year-old woman with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes
physical and psychological abuse, the misuse of property, and the violation of rights.
The typical abuse victim is a woman of advanced age with few social contacts and at
least one physical or mental impairment that limits her ability to perform activities of
daily living. In addition, the client usually lives alone or with the abuser and depends on
the abuser for care.
Q: Which data collection finding would indicate the possibility of the sexual abuse of a
child?, 🗹🗹: Swelling of the genitals
Q: A nurse is assigned to care for a client who is experiencing disturbed thought
processes. The nurse is told that the client believes that the food is being poisoned.
, Page | 2
Which communication technique does the nurse plan to use to encourage the client to
eat?, 🗹🗹: Open-ended questions and silence
Open-ended questions and silence are strategies used to encourage clients to discuss
their problem. Should encourage the client to identify the reasons for the behavior.
Q: A nurse is assigned to care for a client admitted to the hospital after sustaining an
injury from a house fire. The client attempted to save a neighbor involved in the fire but,
in spite of the client's efforts, the neighbor died. Which action would the nurse take to
enable the client to work through the meaning of the crisis?, 🗹🗹: Inquiring about
the client's feelings that may affect coping
The client must first deal with feelings and negative responses before the client is able
to work through the meaning of the crisis.
Q: A nurse is assisting with the data collection on a client admitted to the psychiatric
unit. The nurse reviews the data obtained and identifies which of the following as a
priority concern?, 🗹🗹: The client's report of suicidal thoughts
The client's thoughts are extremely important when verbalized. Suicidal thoughts are
the highest priority.
Q: Laboratory work is prescribed for a client who has been experiencing delusions.
When the laboratory technician approaches the client to obtain a specimen of the
client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The
nurse who is present at the time should respond by stating which of the following?,
🗹🗹: "Are you fearful and think that others may want to hurt you?"
Option 3 is the only option that recognizes the client's need. This response helps the
client focus on the emotion underlying the delusion but does not argue with it. If the
nurse attempts to change the client's mind, the delusion may, in fact, be even more
strongly held
Q: An intoxicated client is brought to the emergency department by local police. The
client is told that the health care provider (HCP) will be in to see the client in about 30
minutes. The client becomes very loud and offensive and wants to be seen by the HCP
immediately. The nurse assisting to care for the client would plan for which appropriate
, Page | 3
nursing intervention?, 🗹🗹: Offer to take the client to an examination room until he
or she can be treated.
Safety of the client, other clients, and staff is of prime concern. When dealing with an
impaired individual, trying to talk may be out of the question. Waiting to intervene
could cause the client to become even more agitated and a threat to others
Q: A client is admitted to a psychiatric unit for treatment of psychotic behavior. The
client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with
me! I don't belong here!" The nurse identifies this behavior as:, 🗹🗹: Denial
Denial is refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and
attributes them to other people, objects, or situations.
In regression, the client returns to an earlier, more comforting, although less mature
way of behaving.
Rationalization is justifying the unacceptable attributes about oneself.
Q: A client says to the nurse, "I'm going to die, and I wish my family would stop hoping
for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's
dying." The therapeutic response by the nurse is:, 🗹🗹: "You're feeling angry that
your family continues to hope for you to be 'cured'?"
Reflection is the therapeutic communication technique that redirects the client's
feelings back to validate what the client is saying.
Q: A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days
ago. On review of the client's record, the nurse notes that the admission was a voluntary
, Page | 4
admission. Based on this type of admission, the nurse would expect which of the
following?, 🗹🗹: The client will participate in the treatment plan.
Generally, voluntary admission is sought by the client or client's guardian. If the client
seeks voluntary admission, the most likely expectation is that the client will participate
in the treatment program.
Q: A licensed practical nurse (LPN) enters a client's room, and the client is demanding
release from the hospital. The LPN reviews the client's record and notes that the client
was admitted 2 days ago for treatment of an anxiety disorder, and that the admission
was a voluntary admission. The LPN reports the findings to the registered nurse (RN)
and expects that the RN will take which of the following actions?, 🗹🗹: Contact the
health care provider (HCP).
Generally, voluntary admission is sought by the client or client's guardian. Voluntary
clients have the right to demand and obtain release. The best nursing action is to
contact the HCP.
Q: A client is admitted to the psychiatric nursing unit. When collecting data from the
client, the nurse notes that the client was admitted on an involuntary status. Based on
this type of admission, the nurse likely expects that the client:, 🗹🗹: Presents a harm
to self
Involuntary admission is made without the client's consent. Involuntary admission is
necessary when a person is a danger to self or others or is in need of psychiatric
treatment or physical care
Q: Following a group therapy session, a client approaches the licensed practical nurse
(LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN
reports the findings to the registered nurse (RN) and expects that the RN will take
which of the following actions?, 🗹🗹: Get a written prescription from the health care
provider (HCP) and obtain an informed consent.
A client may request to be secluded or restrained. Federal laws require the consent of
the client, unless an emergency situation exists in which an immediate risk to the client
or others can be documented. The use of seclusion and restraint is permitted only on
