NCLEX Examination Questions-2023 Updated and Elaborated Mental Health
2023
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NCLEX Examination Questions-2023 Updated and Elaborated Mental Health
2023
3. Characteristics of a therapeutic relationship are exemplified by meeting which goals? Select all that apply.
Answer: 2, 3
□ 3. The nurse encourages the practice of new cop- ing skills.
Rationale: The goal of a therapeutic relationship is to enhance the personal growth of the client. Giving ad- vice, exchanging personal information, and striving to meet the personal needs of the nurse and the client aren’t therapeutic for the client and cross the bound- aries of professionalism. Discussing information from or about the client with family members is a breach of confidentiality unless the client has expressly request-ed that the information be disclosed.
□ 4. The nurse gives advice to the client.
Nursing process step: Implementation Client
□ 5. The nurse and client exchange personal information.
needs category: Psychosocial integrity Client
□ 6. The nurse discusses the client’s feelings with family members.
Cognitive level: Analysis
□ 1. The needs of the client and nurse are identified and met. □ 2. The nurse helps the client explore different problem-solving techniques.
needs subcategory: None
4. A nurse understands that the first step in caring for a client with a mental health illness is to establish a therapeutic relationship to achieve effective communication. Place the phases of a therapeutic relationship in ascending chronological order. Use all the options. 1. Working phase
Answer: 2. Preinteraction phase 4. Orientation phase 1. Working phase
2. Preinteraction phase
3. Termination phase
3. Termination phase
Rationale: The preinteraction phase in the initial phase includes the evaluation of the client by the nurse; the client is not often involved in this phase. The orientation phase is the ”getting-to-know-you” phase in which trust begins to develop. The working phase involves participation by the nurse and client. The final phase is the termination phase, during which time the nurse and client evaluate the goals achieved or not achieved.
4. Orientation phase
Nursing process step: Planning Client needs category: Psychosocial integrity Client needs subcategory: None Cognitive level: Application
PSYCHIATRIC A N D MENTAL HEALTH N U R SING
5. A nurse is explaining the Bill of Rights for psychi- atric clients to a client who has voluntarily sought ad- mission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply.
Answer: 2, 3, 5, 6
□ 4. Right to obtain disability
Rationale: An inpatient client usually receives a copy of the Bill of Rights for psychiatric patients, which in- cludes the right to refuse treatment, the right to a writ- ten treatment plan, the right to confidentiality, and the right to personal mail. However, a client in an inpatient setting cannot select health team members. A client may apply for disability as a result of a chronic, inca- pacitating illness; however, disability is not a patient right, and members of a psychiatric institution do not decide who should receive it.
□ 5. Right to confidentiality
Nursing process step: Implementation Client
□ 6. Right to personal mail
needs category: Psychosocial integrity Client
□ 1. Right to select health care team members □ 2. Right to refuse treatment □ 3. Right to a written treatment plan
needs subcategory: None Cognitive level: Application
6. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, “How long do I have to stay here?” Select all that apply. □ 1. “You may leave the hospital at any time unless you are suicidal, homicidal, or unable to meet basic needs.” □ 2. “Let’s talk more after the health team has as- sessed you.” □ 3. “Once you’ve signed the papers, you have no say.” □ 4. “Because you could hurt yourself, you must be safe before being discharged.”
Answer: 1, 2, 4 Rationale: A person who’s admitted to a psychiatric hospital on a voluntary basis may sign out of the hos- pital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client’s condition before discharge. If there’s reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from volun- tary to involuntary. Saying the client has no say once papers are signed is incorrect because it denies the client’s rights. The client doesn’t need a lawyer to leave the hospital. A hearing isn’t mandated before discharge; a hearing is held only if the client remains unsafe and requires further treatment. Nursing process step: Implementation Client
□ 5. “You need a lawyer to help you make that decision.”
needs category: Psychosocial integrity Client
□ 6. “There must be a court hearing before you leave the hospital.”
Cognitive level: Application
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needs subcategory: None
7. A nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply. □ 1. The client addresses how the addiction has contributed to family distress. □ 2. The client reluctantly shares the family history of addiction. □ 3. The client verbalizes difficulty identifying person- al strengths. □ 4. The client discusses the financial problems relat- ed to the addiction.
Answer: 1, 3, 6 Rationale: In the working phase, the client explores, evaluates, and determines solutions to identified prob- lems. Sharing a family history of addiction, discussing financial problems due to addiction, and expressing uncertainty about meeting the nurse would occur dur- ing the introductory phase of the nurse-client interac- tion. Nursing process step: Evaluation Client needs category: Psychosocial integrity Client needs subcategory: None Cognitive level: Application
□ 5. The client expresses uncertainty about meeting with the nurse. □ 6. The client acknowledges the addiction’s effects on the children.
Anxiety disorders
1. After receiving a referral from the occupational health nurse, a client comes to the mental health clinic with a suspected diagnosis of obsessive-compulsive disorder. The client explains that his compulsion to wash his hands is interfering with his job. Which interventions are appropriate when caring for a client with this disorder? Select all that apply. □ 1. Don’t allow the client time to carry out the ritual- istic behavior. □ 2. Support the use of appropriate defense mecha-nisms. □ 3. Encourage the client to suppress his anxious feelings. □ 4. Explore the patterns leading to the compulsive behavior. □ 5. Listen attentively, but don’t offer feedback. □ 6. Encourage activities such as listening to music.
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Answer: 2, 4, 6 Rationale: Client care should focus on reducing asso- ciated anxiety, fear, and guilt. The client should be en- couraged to use appropriate defense mechanisms and express his feelings of anxiety. Exploring patterns that lead to the compulsive behavior may also be effective. Activities such as listening to music may divert the client’s attention from unwanted thoughts. The client should be allowed to carry out ritualistic behavior until he can be distracted to some other activity. The nurse should always listen attentively to the client and offer feedback. Nursing process step: Implementation Client needs category: Psychosocial integrity Client needs subcategory: None Cognitive level: Application
PSYCHIATRIC A N D MENTAL HEALTH N U R SING
2. After being examined by the forensic nurse in the emergency department, a rape victim is prepared for discharge. Due to the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply.
Answer: 1, 3, 6
□ 4. Flight of ideas
Rationale: Clients diagnosed with PTSD typically experience recurrent, intrusive recollections or night- mares, sleep disturbances, difficulty concentrating, chronic anxiety or panic attacks, memory impairment, and feelings of detachment or estrangement that de- stroy interpersonal relationships. Gingival and dental problems are associated with bulimia. Flight of ideas and unusual talkativeness are characteristic of the acute manic phase of bipolar affective disorder.
□ 5. Unusual talkativeness
Nursing process step: Data collection Client
□ 6. Difficulty concentrating
needs category: Psychosocial integrity Client
□ 1. Recurrent, intrusive recollections or nightmares □ 2. Gingival and dental problems □ 3. Sleep disturbances
needs subcategory: None Cognitive level: Comprehension
3. A physician prescribes clomipramine (Anafranil) for a client diagnosed with obsessive-compulsive disorder. What instructions should the nurse include when teaching the client about this medication? Select all that apply. □ 1. Avoid hazardous activities that require alertness or good coordination until adverse central ner- vous system (CNS) effects are known. □ 2. Avoid alcohol and other depressants. □ 3. Use saliva substitutes or sugarless candy or gum to relieve dry mouth. □ 4. Take the drug on an empty stomach. □ 5. Avoid using over-the-counter (OTC) products, except antihistamines and decongestants, with- out medical permission. □ 6. Discontinue the medication if adverse reactions are troublesome.
Answer: 1, 2, 3 Rationale: Clomipramine, a tricyclic antidepressant used to treat obsessive-compulsive disorder, may cause adverse CNS effects. Therefore, the nurse should warn the client to avoid hazardous activities that require alertness or good coordination until its ef- fects are known. The client should also be instructed to avoid alcohol and other depressants. Dry mouth, a common adverse effect of this medication, can be re- lieved with saliva substitutes or sugarless candy or gum. The nurse should tell the client to take the med- ication with meals (not on an empty stomach), espe- cially during the adjustment period, to minimize ad- verse GI effects. Later, the entire daily dose can be taken at bedtime. The client should check with the physician before taking OTC products because interac- tions may occur. The nurse should encourage the client to continue therapy, even if adverse reactions are troublesome. The client shouldn’t stop taking the medication without medical permission. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Pharmacological therapies Cognitive level: Application
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4. A registered nurse caring for a client with general- ized anxiety disorder identifies a nursing diagnosis of Anxiety. The short-term goal identified is: “The client will identify his physical, emotional, and behavioral re- sponses to anxiety.” Which nursing interventions will help the client achieve this goal? Select all that apply. □ 1. Avoid talking about the client’s sources of stress. □ 2. Advise the client that consuming one glass of red wine per day may lessen his anxiety. □ 3. Explain to the client that expressing his feelings through journal writing may increase his anxiety. □ 4. Observe the client for overt signs of anxiety. □ 5. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. □ 6. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise.
Answer: 4, 5, 6 Rationale: The nurse should observe the client for overt signs of anxiety to assess anxiety and establish care priorities. She should also help the client connect anxiety with uncomfortable physical, emotional, or be- havioral responses. To modify the automatic response to stress, the client needs to connect the anxiety expe- rience with the unpleasant symptoms. The nurse should also introduce the client to new coping strate- gies, such as relaxation techniques and exercise, which can enable him to take personal responsibility for making changes. The nurse should work with the client to identify sources of stress — not avoid talking about it. The nurse should advise the client to avoid using caf- feine, nicotine, and alcohol to cope with anxiety. Nico- tine and caffeine are stimulants; alcohol acts as a de- pressant but, over time, requires increased use to achieve the desired effect, which may lead to alcohol abuse. The nurse should encourage the client to use a journal to record feelings, behaviors, stressful events, and coping strategies used to address anxiety. Docu- mentation may help the client become aware of his anxiety and the ways in which it affects his overall functioning. Nursing process step: Implementation Client needs category: Psychosocial integrity Client needs subcategory: None Cognitive level: Application
5. A nurse is reviewing information with a client on physical signs and symptoms that may be experienced during a panic attack. Which signs and symptoms should the nurse include? Select all that apply.
Answer: 2, 4, 5, 6
□ 2. Shortness of breath
Rationale: Panic attacks can produce physical and cognitive symptoms. Such symptoms include a rapid heart beat, shortness of breath or rapid breathing, rapid speech, dizziness or light-headedness, sweating, abdominal pain, nausea, heartburn, and diarrhea (GI distress).
□ 3. Delayed speech
Nursing process step: Implementation
□ 4. Dizziness
Client needs category: Physiological integrity Client
□ 5. Sweating
needs subcategory: Physiological adaptation Cognitive
□ 6. GI distress
level: Application
□ 1. Bradycardia
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PSYCHIATRIC A N D MENTAL HEALTH N U R SING
6. A client with a panic disorder is prescribed a monoamine oxidase inhibitor. While reviewing discharge teaching, which dietary restrictions related to this medication would the nurse discuss with the client? Select all that apply. □ 1. Caffeine □ 2. Asparagus
Answer: 1, 3, 4, 5, 6 Rationale: Foods and beverages containing tyramine, caffeine, and tryptophan must be avoided. Foods that contain such substances include aged cheeses, sour cream, beer, raisins, bananas, pickled or smoked fish, chocolate, and meats (such as liver, sausage, and bologna). Nursing process step: Implementation
□ 3. Sour cream
Client needs category: Physiological integrity
□ 4. Bananas □ 5. Chocolate
Client needs subcategory: Pharmacological therapies
□ 6. Liver
Cognitive level: Application
Mood, adjustment, and dementia disorders
1. A nurse is caring for a client who talks freely about feeling depressed. During an interaction, the nurse hears the client state, “Things will never change.” What other indications of hopelessness would the nurse look for? Select all that apply.
Answer: 1, 2, 4
□ 3. Preoccupation with delusions
Rationale: Clients who are depressed and express hopelessness also tend to manifest inappropriate ex- pressions of anger, periods of irritability, and feelings of worthlessness. Preoccupation with delusions is usually seen in clients with schizophrenia; it doesn’t typically occur in those who express hopelessness. Intense per- sonal relationships are usually characteristic of clients with borderline personality disorder.
□ 4. Feelings of worthlessness
Nursing process step: Data collection Client
□ 5. Intense interpersonal relationships
needs category: Psychosocial integrity Client
□ 1. Bouts of anger □ 2. Periods of irritability
needs subcategory: None Cognitive level: Analysis
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