NCLEX Style Questions from Mental Health – Flashcards
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A long-term alcoholic arrives in ED. The healthcare provider orders 1mg Ativan PO. What is the expected effect of this medication on this client? a. decreased effect d/t cross-tolerance b. increased effect d/t cross-tolerance c. decreased effect d/t cross-dependence d. increased effect d/t cross-dependence
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a. decreased effect d/t cross-tolerance.
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A patient comes to the ED with the following symptoms: respirations 8, pulse 108, nausea and vomiting, anxiety and muscle tightness and tremor. What is the most likely cause of this patient's symptoms? a. amphetamine withdrawal b. barbituate withdrawal c. barbituate intoxication d. amphetamine intoxication
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b. barbiturate withdrawal
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Is alcoholism a disease?
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Yes! The term disease broadly refers to any condition that impairs normal function, and is therefore associated with dysfunction of normal homeostasis
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What type of assessment tool do you use for those who suffer from substance abuse?
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CAGE Have you ever felt you should cut down on your drinking? Have people ever annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
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If a patient comes to you, with their hands shaking, and asks for more ativan. What do you do?
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Assess the patient first and then have them see the doctor. Patient may be developing an addiction to Ativan and is trying to manipulate you into giving more. Must tell them, you can have your ativan at this time..... and that's it.
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What is the treatment for Alcohol Withdrawal?
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• General hospital care if needed • Follow hospital protocols- safety is # 1 priority • Provide sitter if needed per your assessment (Money is not a concern on NCLEX) • Monitor VS frequently (psychomotor agitation) • Seizure precautions • Point out reality: inform patient hallucinations are part of withdrawal (not permanent, it is part of the withdrawal process) • Adjust room lighting to prevent shadows = cause illusions, which then cause hallucinations NCLEX • Monitor intake and output • Do NOT restrain (better to do a 1-1 due to risk of seizures (safety # 1)
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Why should you adjust lighting in a room for an alcoholic who is going through withdrawal?
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Because shadows cause illusions and illusions cause hallucinations
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In the development of a therapeutic relationship with a new admission with the diagnosis of post self-inflicted GSW to the head. Which of the following is the priority to the nurse? a. Assess your feelings toward this client. b. Assess the client's level of suicidality. c. Assess the client's support systems. d. Assess the client's plan for suicide.
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a. Assess your feelings toward the client.
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A sixteen year-old Asian client requests an outside provider giver her a coining treatment. What is the RN's best response? a. Respect cultural beliefs and allow the treatment. b. Respect the cultural beliefs, but do not allow the treatment in the hospital. c. Educate the family on Western medicine. d. Encourage the client to try accepted practices.
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b. Respect the cultural beliefs, but do not allow the treatment in the hospital.
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A terminal CA client states to the nurse, "I wish my family would stop hoping for a cure. I know I am going to die and I wish they would stop." The nurse's best response is: a. "We can't control our family's feelings." b. "It sounds as though you are feeling angry your family is still hoping for a cure." c. "I can tell you are in acceptance." d. "I will tell the team to arrange a family meeting."
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b. "It sounds as though you are feeling angry your family is still hoping for a cure."
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A client on the psychiatric unit states, "I feel like a bird." The best response for the nurse to make is: a. "You are a patient not a bird." b. "Birds can fly, can you?" c. "That must be distressing for you, you don't look different to me." d. "What you say indicates to me the reason you are in the hospital."
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c. "That must be distressing for you, you don't look different to me."
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List the following diagnosis on its appropriate axis: Moderate legal problems COPD Antisocial personality disorder 20 Paranoid schizophrenia
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Axis I: paranoid schizophrenia Axis II: Antisocial personality disorder Axis III: COPD Axis IV: Moderate legal problems Axis V: 20
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The group leader states, "We are not along in the daily problems we encounter." this statement reflects which curative factor? a. Altruism b. Imitative behavior c. Universality d. Imparting of information
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c. Universality
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Nurse Jones decides to respect a family wishes and not tell a client of his terminal status because it would bring the most happiness to the most people. Which ethical theory would support her action? a. utilitarianism b. Christina ethics c. Kantianism d. ethical egoism
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a. utilitarianism
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Jimmy is restless and pacing. The nurse states, "If you don't be still, I'm going to put you in restraints." Which legal action might this nurse be charged with? a. defamation of character b. battery c. breach of confidentiality d. assault
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d. assault
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A client comes to the nurse with the following symptoms: anger with periods of threatening the nurse, fear that he is going to be killed at the hospital and that he is unable to do anything about the situation. What level of anxiety is this client experiencing? a. severe b. mild c. panic d. moderate
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c. panic
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The nurse is working with a client who is fearful of flying. Which defense is the client using? a. denial b. rationalization c. projection d. displacement
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d. displacement
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Which client is most at risk for the development of PTSD? a. rescued client trapped under a collapsed roof of a building. b. client who witnessed friend die next to him after explosion. c. mother of a deceased victim in the explosion. d. best friend of a victim who saw the explosion on TV
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a. rescued client trapped under a collapsed roof of a building. (He didn't know if he was going to die or not)
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A man who is getting married suddenly cannot walk. What is this man's most likely diagnosis? a. somatization disorder b. phobia disorder c. conversion disorder d. post traumatic stress disorder
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c. conversion disorder
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A client with pain disorder had a pm for pain 1 hour ago, his next dose is not due for 3 hours. He is now at the nursing station demanding pain medication. What is the nurse's best action? a. call the healthcare provider b. advise the client to go to his room c. assess the client and advise him his medication will be given in 3 hours
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c. assess the client and advise him his medication will be given in 3 hours
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A 40 y/o male client has just been advised he is HIV positive. He asks the nurse, "why did this have to happen to me?" What feeling may this client be experiencing? a. anger b. denial c. guilt d. depression What is the nurse's best response based on the assessment of the client's feelings?
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c. guilt If you lay the ground work for acceptance, it goes smoothly
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The RN must inform a family member his mother has just died. When informed of this news, the 35 year old son smiles and states he is going to the vending machine to buy some candy. What is the most appropriate intervention for the nurse to make at this time? a. allow him to go and sort out his feelings b. repeat, "I just told you your mother died, how do you feel about this?" c. how the healthcare provider meet with the son d. ask him if he would like time alone with his mother
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b. repeat, "I just told you your mother died, how do you feel about this?" He might be in shock. Ask how he feels about the situation.
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A client is diagnosed with Major Depression. What is the most important part of the mental status exam to assess? a. judgement b. mood c. insight d. behavior
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b. mood
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What activity is most appropriate for a client diagnosed with Major Depression? a. group therapy b. one on one baking activity with the nurse c. game of chess with the nurse d. coloring activity with the nurse
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b. one on one baking activity with the nurse (helps get anger out, like kneading dough) Coloring is for schizophranic
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A client comes into the hospital with the following complaints: Her husband is filing for divorce, her 14 year old daughter us refusing to attend school and isolates, she may be in danger of losing her job and her dog has just died. What is your first question to this client? What type of intervention is most appropriate?
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1. "What bothers you the most?' 2. Give the client a sense of control, structure/program
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A client is scheduled for ECT. What family teaching should the RN focus on? a. education on the importance of airway maintenance. b. education on the client's memory loss c. education on the use of brevital as a anesthesia d. education on the purpose of ECT
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b. education on the client's memory loss Education on the purpose of ECT (ALREADY SCHEDULED!!!)
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Which client is most at risk for committing suicide? a. mother who's son just died b. elderly, single male with CA c. Teenager who broke up with his girlfriend d. married business man with alcoholism
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b. elderly, single man with CA
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The ED calls the nurse and states a suicidal client needs a bed on her unit. Hospital policy states suicidal clients must have a room with locked windows. The only room with locked windows is occupied by a post-op client who has been in pain all day and is now finally sleeping. What is the nurse's best action? a. move the post-op patient and put the suicidal client in the room with locked windows b. advise the ED you cannot accept the client until the morning c. accept the suicidal client and place on a 1-1 in another room until morning
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a. move the post-op patient and put the suicidal client in the room with locked windows
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What is a good lunch for a manic client? a. ribs with mashed potatoes b. Peanut butter sandwich and a carton of milk c. pizza, cake, and ice cream d. Cheese burger and fries
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b. Peanut butter sandwich and a carton of milk
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A male client is coming down from a manic period. He states, "I feel bad about cheating on my wife." What is the nurse's best respnse? a. "You can't help it. It's part of your illness." b. "Let's discuss your feelings with your wife." c. "Hypersexuality is part of your illness. Let's discuss early signs of a manic episode."
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c. "Hypersexuality is part of your illness. Let's discuss early signs of a manic episode."
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What activity is most appropriate for a bipolar client? a. a game of twister b. a football game with other clients c. riding on the stationary bike d. coloring activity with the nurse
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c. riding on the stationary bike
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The RN is speaking on the phone with the healthcare provider. A client with the diagnosis of Antisocial PD approaches the RN and demands to speak with her immediately. How should the RN respond? a. put down the phone and assess the client's needs b. ask another nurse to assess the client c. Advise the client you will speak with him when you are finished with the call d. Set a strict verbal limit on the client's behavior
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c. Advise the client you will speak with him when you are finished with the call
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Which characteristics should a nurse expect to observe in an individual experiencing borderline personality disorder? Select all that apply. a. erratic emotions, including anger and depression b. a preference for being alone c. chronic feelings of emptiness or boredom d. Impulsive and unpredictable behavior
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a. erratic emotions, including anger and depression c. chronic feelings of emptiness or boredom d. Impulsive and unpredictable behavior
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What is a good activity for a client diagnosed with paranoid schizophrenia? a. hide and seek b. allow the client to initiate the activity c. coloring in a coloring book d. video game with the nurse
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b. allow the client to initiate the activity
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A family bring in a non-responsive client. The family reports the client is catatonic due to schizophrenia, has a history of diabetes, seizures, COPD. What is the nurse's initial actions? a. begin seizure precautions b. ask the family how long the client has been unresponsive c. check the client's blood sugar d. attach a pulse ox to the client
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c. check the client's blood sugar
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A client asks the nurse if he hear the devil talking. What is the nurse's best response? a. "No I do not hear the devil." b. "You are safe. The devil is not here." c. "Let's go to a quiet place." d. "Even though the voice seems real to you. I do not hear the voice speaking."
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d. "Even though the voice seems real to you. I do not hear the voice speaking."
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Which of the below symptoms are positive signs of schizophrenia? Select all that apply. a. visual hallucinations b. making up words c. withdrawal d. agitation e. introducing unrelated topics
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a. visual hallucinations b. making up words d. agitation e. introducing unrelated topics
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Which of the following are negative symptoms of schizophrenia? Select all that apply. a. Loose associations b. Religious delusions c. Woman laughs when told of a death of friend d. Man lives in his own fantasy world e. Body part of client stuck in one position d. Lack of motivation to get up
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c. Woman laughs when told of a death of friend d. Man lives in his own fantasy world e. Body part of client stuck in one position d. Lack of motivation to get up
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A client is starring at the wall and laughing. What is the first action of the nurse? a. tell the client there is nothing funny on the wall b. ask the client what he is experiencing c. distract the client by asking him to play a game with the nurse d. ask the client if he is feeling anxious
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b. ask the client what he is experiencing
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A schizophrenic client begins to masturbate in the day room. What is the nurse's initial action? a. tell the other clients to leave the day room for a few minutes. b. tell the client this behavior is inappropriate c. ask the client if he is feeling anxious d. ask the client if he needs privacy and escort him to his room
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d. ask the client if he needs privacy and escort him to his room "inappropriate" they may not understand what inappropriate is or means.
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The RN on the adolescent mental health unit has just been informed a male with a diagnosis of conduct disorder is to be admitted to the unit. What is the RN's first priority when this client arrives? a. advise him of the consequences of acting out on the unit. b. review the unit rules with the client. c. read the client his mental health rights. d. educate him on the unit activities and program.
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b. review the unit rules with the client.
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A female comes into the ED and reports she has just been raped. What is the nurse's first priority? a. encourage the client to ventilate her feelings b. instruct her to remove her clothes carefully and place them in a paper bad c. obtain a description of the perpetrator d. stabilize her medical injuries
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b. instruct her to remove her clothes carefully and place them in a paper bad (Must do this before being able to assess and stabilize her medical injuries
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What teaching by the nurse is most important prior to the discharge of an abused or domestic violence victim? a. how to use verbal deescalation b. maintaining a calm attitude c. What is the plan if it happens again d. support groups in the community
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c. What is the plan if it happens again
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Which of the following is a good activity for a demented client? a. doing a crossword puzzle with the nurse b. writing down feelings in a journal c. looking at pictures of her family from the past and discussing d. reading a simple book with large print
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c. looking at pictures of her family from the past and discussing
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List the components of the mini-mental status exam. Select all that apply. a. memory b. orientation c. draw an object d. complete a sentence e. follow a written direction f. perform a calculation
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a. memory b. orientation c. draw an object d. complete a sentence e. follow a written direction f. perform a calculation
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The nurse asks the client the following. "What does this mean,'don't cry over spilled milk.'" a. memory b. recall c. concrete thinking d. comprehension
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c. concrete thinking
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A confused elderly client who arrived to the ED without paperwork refuses to have an NG placed. The healthcare provider insists on the procedure. What is the nurse's best action? a. check for an advanced directive b. check for a durable power of attorney c. advise the healthcare provider privately this action would be a form of abuse d. call the nursing house supervisor e. obtain permission from the family
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c. advise the healthcare provider privately this action would be a form of abuse
