You choose the therapeutic response, the safety priority, and the cue that means the patient is getting worse. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five mental health questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
A. mild.
B. moderate.
C. severe.
D. panic.
Show answer and rationale
Correct answer: C — severe.
Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.
Question 2
A two-year-old has been in the hospital for 3 weeks and has seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
A. Guilt
B. Trust
C. Separation anxiety
D. Shame
Show answer and rationale
Correct answer: C — Separation anxiety
The correct answer is 'Separation anxiety.' Separation anxiety is a common response in young children when they are separated from their primary caregivers for extended periods. In this case, the two-year-old being in the hospital for three weeks and not being able to see family members due to isolation precautions can trigger separation anxiety. 'Guilt' is a feeling of responsibility for wrongdoing, which is not the most likely change occurring in this scenario. 'Trust' involves reliance and confidence in others, not typically associated with prolonged separation from family. 'Shame' is a negative emotion related to feeling disgrace, which is not the most appropriate response in this hospitalization situation.
Question 3
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with
A. wearing clothing that is too small for the child
B. the child being shaken
C. falling while learning to walk
D. parents trying to awaken the child
Show answer and rationale
Correct answer: B — the child being shaken
The correct answer is 'the child being shaken.' Children who are shaken are frequently grasped by both upper arms, leading to bruises in that area. The presentation of a difficult-to-awaken child with bruises on the upper arms is highly concerning for non-accidental trauma, such as abusive shaking. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely because the combination of a child being difficult to awaken and bruises on both upper arms is highly suggestive of non-accidental trauma rather than benign causes like ill-fitting clothing, falling while learning to walk, or parents trying to awaken the child.
Question 4
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
A. "I am having difficulty paying for this new antibiotic the physician prescribed."?
B. "I am a little short on cash since my daughter moved in to help me."?
C. "I have not felt like shopping since the weather has gotten worse."?
D. "People do not realize how difficult it is to make ends meet on a fixed income."?
Show answer and rationale
Correct answer: B — "I am a little short on cash since my daughter moved in to help me."?
The correct answer is B: "I am a little short on cash since my daughter moved in to help me."? This statement raises suspicion of financial abuse as it suggests a recent change in financial circumstances after the daughter moved in. Financial abuse in elderly clients can be indicated by sudden unexplained financial deficits or changes, such as difficulty paying for necessities despite previously being able to do so. Choices A, C, and D do not directly imply a recent financial change due to external factors, making them less indicative of potential financial abuse. Option B is the most concerning statement that warrants further investigation into possible financial exploitation.
Question 5
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:
A. report a positive self-concept.
B. identify negative thoughts.
C. recognize positive thoughts.
D. give one positive cue with each negative cue
Show answer and rationale
Correct answer: A — report a positive self-concept.
The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.
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Question 6
Implementing counseling by the nurse specialist for the raped victim represents:
A. assessment.
B. crisis intervention.
C. empathetic concern.
D. unwarranted intrusion.
Correct answer:
Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (Choice C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (Choice A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (Choice D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
A. whole brain death.
B. heart-lung death.
C. circulatory death.
D. higher brain death.
Correct answer:
The correct answer is 'whole brain death.' Most protocols for determining whole brain death require two separate clinical examinations, including the induction of painful stimuli, pupillary responses to light, oculovestibular testing, and apnea testing. This comprehensive approach ensures that all functions of the brain, including the brainstem, are evaluated to confirm the absence of brain function. Choices B and D are incorrect as they do not reflect the specific tests required for determining whole brain death. Choice C, 'circulatory death,' does not involve the evaluation of brain function and is not a current definition of death in the United States.
Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?
A. They have a high energy-to-fluid-volume ratio.
B. Even though hypertonic, they are well tolerated.
C. They are a basic solution due to the addition of sodium hydroxide (NaOH).
D. The pH is alkaline, making them compatible with most medications.
Correct answer:
The correct statement is that fat emulsions have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories, respectively, for each milliliter. In comparison, a milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices B, C, and D are incorrect. Choice B is false because fat emulsions are essentially pH neutral and isotonic, not hypertonic. Choice C is incorrect because fat emulsions are not basic solutions; they are essentially pH neutral. Choice D is incorrect as fat emulsions are not alkaline; they are pH neutral, making them compatible with most medications.
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
A. wearing clothing that is too small for the child.
B. the child being shaken.
C. falling while learning to walk.
D. parents trying to awaken the child.
Correct answer:
The correct answer is 'the child being shaken.' In cases of suspected child abuse, bruises on both upper arms can be indicative of a child being shaken, as children who are shaken are frequently grasped by both upper arms. The presentation of a 10-month-old child being difficult to awaken, along with bruises on the upper arms, raises concern for inflicted injury. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely in this scenario as they do not align with the concerning signs of suspected abuse indicated by the bruises and the child's altered level of consciousness.
A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about
A. the pathophysiology and behavioral manifestations of schizophrenia.
B. support groups that can help the parents cope with their frustration.
C. the prolonged recovery time and side effects of medications to prevent relapse.
D. motivational techniques that are effective in engaging clients with schizophrenia.
Correct answer:
The nurse conducting discharge teaching must emphasize the extended recovery process and the potential side effects of medications used to prevent relapse in individuals with schizophrenia. In this scenario, it is crucial for the parents to understand that the client's behavior may be influenced by the medication's sedative qualities and the time required for full recovery. While support groups can assist caregivers in coping with their emotions and providing better care, the priority here is educating on the recovery process and medication effects. Motivational techniques are beneficial but may not be the immediate focus in this situation.
When helping a client gain insight into anxiety, the nurse should:
A. help the client relate anxiety to specific triggers.
B. ask the client to describe events that precede increased anxiety.
C. encourage the client to practice relaxation techniques.
D. address the client's resistive behavior.
Correct answer:
When assisting a client in gaining insight into anxiety, it is crucial to explore the events that lead to increased anxiety. By asking the client to describe these events, the nurse can help the client recognize patterns and triggers, leading to a better understanding of their anxiety. Option A is incorrect because it refers to triggers rather than exploring the events leading to anxiety. Option C is incorrect as it focuses on relaxation techniques rather than delving into the root causes of anxiety. Option D is inappropriate as addressing resistive behavior may not foster a supportive therapeutic environment for the client.
What are the three major sequential maturational crises for females?
A. puberty, pregnancy, and menopause.
B. death of a spouse, menopause, and childbirth.
C. rape, divorce, and menarche.
D. dating, engagement, and separation.
Correct answer:
The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. Puberty signifies the beginning of menarche, the first menstrual period. Pregnancy is a transformative experience with long-lasting effects on a woman's life. Menopause marks the end of menstrual cycles. These milestones are well-documented in research and are significant events in a woman's life. Nurses play a vital role in supporting females through these stages. Choices B, C, and D are incorrect as they do not accurately represent the recognized sequential maturational crises in a female's life.
A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.
A. "You feel inadequate because you have never learned to balance a checkbook."?
B. "You should have insisted your husband teach you about the finances."?
C. "You are strong and will learn how to manage your finances after a while."?
D. "I believe in your strength to learn how to manage your finances in time."?
Correct answer:
The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
A. "Tell me more specifically about her complaints."?
B. "Can you think of reasons why she might nag you so much?"?
C. "I'll help you think about how to bring this up yourself tomorrow afternoon."?
D. "Why do you want me to initiate this in tomorrow's session rather than you?"?
Correct answer:
The most therapeutic response is to empower the client to address the issue himself. By offering assistance in thinking about how to bring up the topic during the family session, the nurse is promoting the client's autonomy and communication skills. This response encourages the client to take an active role in resolving the situation. Choices A and B focus on the wife's behavior, which is not the immediate concern during this interaction. Choice D challenges the client's request and shifts the responsibility back to the client, potentially hindering progress and discouraging open communication.
What is a common characteristic of individuals who become batterers?
A. Grew up in a loving, secure home.
B. Was an only child.
C. Was physically or psychologically abused.
D. Admits they have a problem with anger.
Correct answer:
The correct answer is 'Was physically or psychologically abused.' Research indicates that many individuals who become batterers have a history of being abused themselves. This cycle of abuse can influence their behavior as adults. Choice A is incorrect because growing up in a loving home does not necessarily prevent someone from becoming a batterer. Choice B is incorrect as being an only child is not a determining factor in becoming a batterer. Choice D is incorrect because while admitting to anger issues is a positive step, it is not a common characteristic of individuals who become batterers.
NCLEX-PN mental health practice questions, set 2 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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