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-RN exam guide or more NCLEX-RN 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
What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?
A. Encouraging the father to participate in a parenting class
B. Providing time for the father to be alone with and get to know the baby
C. Offering the father a demonstration on newborn diapering, feeding, and bathing
D. Allowing time for the father to ask questions after viewing a film about a new baby
Show answer and rationale
Correct answer: B — Providing time for the father to be alone with and get to know the baby
The priority nursing action to assist an anxious father in his concern about not bonding with his newborn is providing time for the father to be alone with and get to know the baby. Time alone provides the opportunity for paternal-infant attachment and bonding, which can help reduce the father's anxiety. Encouraging the father to participate in a parenting class, although helpful, does not directly address the immediate need for bonding. Offering a demonstration on newborn care tasks like diapering, feeding, and bathing may not effectively address the father's anxiety at that moment, as he may not be ready to absorb such information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach that may not adequately address the emotional needs and concerns of the father regarding bonding with his newborn.
Question 2
What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?
A. Encouraging the father to participate in a parenting class
B. Providing time for the father to be alone with and get to know the baby
C. Offering the father a demonstration on newborn diapering, feeding, and bathing
D. Allowing time for the father to ask questions after viewing a film about a new baby
Show answer and rationale
Correct answer: B — Providing time for the father to be alone with and get to know the baby
The priority nursing action to assist an anxious father in his concern about not bonding with his newborn is providing time for the father to be alone with and get to know the baby. Time alone provides the opportunity for paternal-infant attachment and bonding, which can help reduce the father's anxiety. Encouraging the father to participate in a parenting class, although helpful, does not directly address the immediate need for bonding. Offering a demonstration on newborn care tasks like diapering, feeding, and bathing may not effectively address the father's anxiety at that moment, as he may not be ready to absorb such information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach that may not adequately address the emotional needs and concerns of the father regarding bonding with his newborn.
Question 3
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
A. At home, I take my pills at 8:00 am.
B. It costs a lot of money to buy all of these pills.
C. I get so tired of taking pills every day.
D. This is a new pill I have never taken before.
Show answer and rationale
Correct answer: D — This is a new pill I have never taken before.
The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.
Question 4
The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
B. Recopy the care plan without the resolved diagnosis
C. Write a nursing progress note indicating that the outcome goals have been achieved
D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Show answer and rationale
Correct answer: D — Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
Question 5
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family's home environment
Show answer and rationale
Correct answer: D — Description of the family's home environment
When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.
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Question 6
The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level
Correct answer:
Long-term protein deficiency significantly lowers serum albumin levels. Albumin, derived from protein breakdown, is produced by the liver when adequate amino acids are available. Due to its long half-life, acute protein loss minimally affects serum albumin levels. In contrast, serum transferrin, with a shorter half-life of 8 to 10 days, decreases with acute protein deficiency and is not a reliable indicator of chronic protein malnutrition. Elevated hemoglobin levels may occur in conditions like dehydration or chronic obstructive pulmonary disease, making it an unreliable indicator of chronic protein malnutrition. High cholesterol levels are not directly linked to protein malnutrition and do not serve as a reliable indicator. Therefore, the most reliable indicator of chronic protein malnutrition among the options provided is a low serum albumin level.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
A. Consult with the pharmacist about the need to continue the medication.
B. Administer the antihypertensive medication as prescribed preoperatively.
C. Withhold the medication until the client is fully alert and vital signs are stable.
D. Contact the health care provider to renew the prescription for the medication.
Correct answer:
In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?
A. Educate the client on managing stress.
B. Teach the client to maintain a balanced diet.
C. Instruct the client to have regular health checkups.
D. Ask the client to use sunscreen when working outdoors.
Correct answer:
The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?
A. Educate the client on managing stress.
B. Teach the client to maintain a balanced diet.
C. Instruct the client to have regular health checkups.
D. Ask the client to use sunscreen when working outdoors.
Correct answer:
The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct answer:
The Good Samaritan Act protects healthcare professionals who provide care in good faith from malpractice claims, regardless of the client outcome. In this scenario, the nurse stopped at the scene voluntarily to render aid, which is protected under the Good Samaritan Act. This law shields individuals from legal liability when providing emergency care in good faith and without expectation of compensation. The Patient's Bill of Rights does protect clients, but in this case, the nurse's actions were protected by the Good Samaritan Act. Additionally, the state Board of Nursing would not likely revoke the nurse's license unless there was evidence of actions taken in bad faith or unreasonable care. The client would not win the lawsuit as the essential elements of malpractice, including duty, breach, causation, and damages, were not met in this situation.
The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by the nurse is most appropriate?
A. Avoid asking questions unless the patient initiates the conversation.
B. Ask the patient whether it is important that cultural healers are contacted.
C. Explain the usual hospital routines for meal times, care, and family visits.
D. Obtain further information about the patient's cultural beliefs from a family member.
Correct answer:
When caring for a patient with traditional health beliefs, it is essential to respect and address their cultural practices. Asking the patient whether it is important to involve cultural healers, such as a shaman, aligns with providing culturally sensitive care. Avoiding asking questions unless initiated by the patient may hinder effective communication and understanding of the patient's needs. Consulting a family member for cultural beliefs assumes that all family members share the same beliefs, which may not be accurate. Additionally, the patient's personal beliefs should be prioritized over family input. Explaining hospital routines without considering the patient's cultural preferences may lead to a lack of patient-centered care. Therefore, the most appropriate action is to inquire about the patient's preference regarding cultural healers.
When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct answer:
Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct answer:
Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
A. Notify the friend that all medical information will be kept confidential.
B. Explain the relationship to the charge nurse and ask for reassignment.
C. Approach the client and ask if the assignment is uncomfortable.
D. Accept the assignment but protect the client's confidentiality.
Correct answer:
When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.
A client who just had a bilateral mastectomy is preparing to talk about body changes. Which of the following actions of the nurse is most appropriate during this discussion?
A. Provide a room that offers minimal distractions
B. Ask closed-ended questions to allow the client to think about her situation
C. Write detailed notes during the conversation to track important information
D. Ask personal questions about the client's background to determine how the procedure has affected her self-concept
Correct answer:
When preparing to discuss sensitive topics such as body changes post-bilateral mastectomy, it is crucial to create a conducive environment. Providing a room with minimal distractions allows the client to feel comfortable, safe, and more likely to open up about personal feelings without interruptions. This setting fosters open communication between the nurse and client, facilitating a more empathetic and supportive interaction. Closed-ended questions (Choice B) may limit the client's ability to express emotions fully. Writing detailed notes (Choice C) during the conversation may distract the nurse from actively listening and being present for the client. Asking personal questions about the client's background (Choice D) may not be appropriate during such a vulnerable discussion and could potentially create discomfort for the client.
NCLEX-RN mental health practice questions, set 3 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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