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 best intervention for a client with borderline personality disorder?
A. Establishing clear boundaries
B. Exploring vocational possibilities
C. Discussing feelings of victimization
D. Spending 1 to 2 hours per day with the client
Show answer and rationale
Correct answer: A — Establishing clear boundaries
The best intervention for a client with borderline personality disorder is to establish clear boundaries. Individuals with this disorder struggle with impulsivity and have difficulty recognizing and respecting boundaries in their relationships. By establishing clear boundaries, it helps provide structure and consistency to the client, aiding in their treatment and management of the disorder. Exploring vocational possibilities may be important at some point, but it is not the priority intervention for managing borderline personality disorder. Discussing feelings of victimization, while common, may not be as effective initially due to the client's lack of insight and resistance. Spending 1 to 2 hours per day with the client may not be as productive as shorter, more focused interactions that are geared towards boundary reinforcement.
Question 2
What is the best intervention for a client with borderline personality disorder?
A. Establishing clear boundaries
B. Exploring vocational possibilities
C. Discussing feelings of victimization
D. Spending 1 to 2 hours per day with the client
Show answer and rationale
Correct answer: A — Establishing clear boundaries
The best intervention for a client with borderline personality disorder is to establish clear boundaries. Individuals with this disorder struggle with impulsivity and have difficulty recognizing and respecting boundaries in their relationships. By establishing clear boundaries, it helps provide structure and consistency to the client, aiding in their treatment and management of the disorder. Exploring vocational possibilities may be important at some point, but it is not the priority intervention for managing borderline personality disorder. Discussing feelings of victimization, while common, may not be as effective initially due to the client's lack of insight and resistance. Spending 1 to 2 hours per day with the client may not be as productive as shorter, more focused interactions that are geared towards boundary reinforcement.
Question 3
Which nursing action promotes psychosocial development for a newborn?
A. Washing hands before holding the newborn
B. Measuring the newborn using an approved length board
C. Weighing the newborn on the same scale during hospitalization
D. Placing the newborn in the mother's arms during the first hour of life
Show answer and rationale
Correct answer: D — Placing the newborn in the mother's arms during the first hour of life
Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being.
Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.
Question 4
A 37-year-old woman with a history of fibroids and menorrhagia that have not been responsive to hormonal treatments is admitted with severe menorrhagia resulting in anemia. She also has depression and pelvic pain. She is crying and states, 'I don't know what to do"?my primary health care provider is recommending a hysterectomy, but I haven't had children yet!' Which response would the nurse provide?
A. 'There are so many children up for adoption, looking for a mother.'
B. 'This must feel so difficult for you. Children are really important to you?'
C. This must feel so difficult for you. Although Children should not be important to you.'
D. Believe me when I tell you that kids are so difficult to raise"?you're better off without them.'
Show answer and rationale
Correct answer: B — 'This must feel so difficult for you. Children are really important to you?'
The correct response is to acknowledge the client's feelings and provide an open-ended question to encourage further expression. By expressing empathy and understanding, the nurse can create a supportive environment for the client. This approach allows the client to explore her emotions and concerns freely. Option A, suggesting adoption, may come across as dismissive of the client's current emotional state and may not address her immediate needs. Option D is insensitive and dismissive of the client's feelings and desires regarding having children. It is important to avoid making assumptions or judgments about the client's situation. Option C is a duplicate of Option B, and while it shows empathy, it lacks variety in communication, which may limit the depth of the conversation and the nurse's understanding of the client's needs.
Question 5
Which of the following is an age-related developmental task for a 68-year-old client?
A. Dealing with loss of friends
B. Commitment to parenthood
C. Setting career goals
D. Solidification of sense of self
Show answer and rationale
Correct answer: A — Dealing with loss of friends
As individuals age, they face various developmental tasks unique to that stage of life. For a 68-year-old client, dealing with the loss of friends becomes a significant aspect of their development. This age group often experiences the passing of peers and friends, leading to feelings of loneliness and the need to adjust to a changing social circle. Commitment to parenthood (Choice B) is more relevant to younger adults in their child-rearing years. Setting career goals (Choice C) is typically associated with early to mid-career stages rather than later in life. Solidification of sense of self (Choice D) is a task that is more commonly associated with earlier adulthood when individuals are establishing their identity. Therefore, the most appropriate developmental task for a 68-year-old client is dealing with the loss of friends.
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Question 6
According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit?
A. The child develops the superego.
B. The child plays beside other children.
C. The child concentrates on work and play.
D. The child becomes casual about body appearance.
Correct answer:
According to Erikson's theory, a preschooler develops the superego or conscience during the initiative versus guilt stage. This stage occurs around ages 3 to 6 years old. The development of the superego is crucial for the child to start understanding and internalizing societal and parental values. Choice B is incorrect because playing beside other children typically occurs during the autonomy versus shame and doubt stage, which is seen in toddlers. Choice C is incorrect as concentrating on work and play is more characteristic of the industry versus inferiority stage, typically seen in school-aged children. Choice D is incorrect because becoming casual about body appearance is more aligned with the identity versus role confusion stage, which is seen in adolescents who have a marked preoccupation with appearance and body image.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Correct answer:
When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
A. Review the client's weight pattern over the year
B. Ask the mother to record her diet for the last 24 hours
C. Encourage her to talk about her view of herself
D. Give her several pamphlets on postpartum nutrition
Correct answer:
Encouraging the adolescent client to talk about her view of herself is the first action the nurse should take. Body image is crucial for adolescents, especially after pregnancy. By addressing the client's concerns about her weight and discussing her self-perception, the nurse can provide emotional support and open a dialogue for further assessment and teaching.
Choice A, 'Review the client's weight pattern over the year,' is not the priority at this time as the client's immediate concern is her post-pregnancy weight. Choice B, 'Ask the mother to record her diet for the last 24 hours,' focuses on dietary habits rather than addressing the client's emotional concerns. Choice D, 'Give her several pamphlets on postpartum nutrition,' may be helpful but should come after addressing the client's emotional needs and concerns.
Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?
A. ''Tell me about the relationship that you have with your mother and father.''
B. ''Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
C. ''What is the main thing that you would like to work on during therapy?'
D. ''I understand that you have been depressed. What can you tell me about that?'
Correct answer:
In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
A. Encourage the client to increase ambulation in the room.
B. Offer the client a high-carbohydrate snack for energy.
C. Force fluids to thin the client's pulmonary secretions.
D. Determine if pain is causing the client's tachypnea.
Correct answer:
When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.
Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?
A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
B. A client reads a story about a traumatic event and then visualizes the result
C. A client focuses on a negative thought in their mind while tapping their fingers
D. None of the above
Correct answer:
Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.
A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?
A. Contact an interpreter to give the information again in the father's native language
B. Continue to provide information about surgery to both the client and his parents
C. Call social services to evaluate the parent's standard of care
D. Contact the physician about postponing the surgery
Correct answer:
Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.
A parent of a young child says, 'I'm so upset! The doctor prescribed an antidepressant!' Which response is best?
A. Tell me more about what's bothering you.'
B. Weren't you told about the need for the medication?'
C. I'll notify the healthcare provider about your concerns.'
D. 'Maybe the medication is for attention deficit disorder.'
Correct answer:
The best response in this situation is to express empathy and encourage the parent to share more about their concerns. Option A ('Tell me more about what's bothering you.') allows the nurse to show understanding and gather more information to address the parent's distress effectively. Option B ('Weren't you told about the need for the medication?') is confrontational and may make the parent defensive, hindering effective communication. Option C ('I'll notify the healthcare provider about your concerns.') is premature; the nurse should first assess the parent's feelings before deciding on further actions. Option D ('Maybe the medication is for attention deficit disorder.') assumes without clarification, which is not appropriate; the nurse should validate the prescription before suggesting alternative reasons.
Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:
A. document the other worker's assessment of the patient.
B. assess the patient based on data collected from all sources.
C. validate the worker's impression by contacting the patient's significant other.
D. discuss the worker's impression with the patient during the assessment interview
Correct answer:
The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.
Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?
A. I send my child to their bedroom for misbehaving.
B. We limit time-out to 4 minutes per incident.
C. Putting my child in a dark closet for time-out is very effective.
D. I explain the reason for the time-out before and after disciplining my child.
Correct answer:
The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child's association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child's trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.
NCLEX-RN mental health practice questions, set 4 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-RN exam guide.
The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
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