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
During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important?
A. Understanding what will be discussed
B. Knowing that the nurse is trying to be helpful
C. Knowing what to expect from the relationship
D. Preparing for termination of the relationship
Show answer and rationale
Correct answer: C — Knowing what to expect from the relationship
During the initial stages of a therapeutic relationship, having a clear understanding of participants' roles is crucial as it helps in defining the structure and boundaries of the relationship. This clarity assists in setting expectations and establishing a framework for interaction, allowing the client to focus on the therapeutic process rather than on uncertainties regarding their role or the nurse's role. Option A, understanding what will be discussed, is important but not directly related to defining roles. Option B, knowing that the nurse is trying to be helpful, is about the intent of the nurse rather than the roles of the participants. Option D, preparing for termination of the relationship, is premature in the beginning phase and not directly related to understanding roles.
Question 2
A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?
A. Implement suicide precautions.
B. Frequently offer high-calorie snacks and fluids.
C. Assist the patient to identify three personal strengths.
D. Observe patient for therapeutic effects of antidepressant medication.
Show answer and rationale
Correct answer: A — Implement suicide precautions.
Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.
Question 3
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client's fluid intake to prevent diarrhea.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift.
Show answer and rationale
Correct answer: A — Perform range-of-motion exercises to prevent contractures.
Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.
Question 4
When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.
Show answer and rationale
Correct answer: B — Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.
Question 5
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practices?
A. Spiritual beliefs
B. Family practices
C. Emotional factors
D. Cultural background
Show answer and rationale
Correct answer: B — Family practices
The correct answer is 'Family practices.' In this scenario, the client's health practices are influenced by the fact that her family members never had annual gynecologic examinations, leading her to believe that such preventive care measures are unnecessary. This highlights the impact of familial behavior on an individual's perception of healthcare. Spiritual beliefs are not the primary factor at play here; they may affect the choice of medical treatment but not the decision to seek preventive care. Emotional factors like stress or fear could influence health practices, but there is no indication of this in the client's case. Cultural background would come into play if the client followed specific health beliefs or customary practices related to illness and health restoration.
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Question 6
A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?
A. Client will verbalize that depression symptoms have lifted
B. Client will identify life stressors that may be contributing to depression
C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy
Correct answer:
In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management.
Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
A. Review the chart for a signed consent for medication administration.
B. Get the guardian's permission to give the medication.
C. Do not give the medication and document the reason.
D. Complete an incident report and notify the supervisor.
Correct answer:
In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.
Which of the following is a typical assessment finding of a 24-year-old female with anorexia nervosa?
A. Weight loss of more than 2% body fat
B. Frequent binge-eating episodes followed by induced vomiting
C. A history of poor academic performance and mediocre achievements
D. Lack of menstruation
Correct answer:
The correct answer is D: Lack of menstruation. Amenorrhea, or lack of menstruation, is a common occurrence in individuals with anorexia nervosa. The induced starvation from anorexia can disrupt hormone levels, leading to menstrual irregularities. This hormonal imbalance can result in amenorrhea, which can have long-term consequences such as osteoporosis and infertility. Choices A, B, and C are incorrect. Weight loss of more than 2% body fat may be a consequence of anorexia but is not a specific assessment finding. Frequent binge-eating episodes followed by induced vomiting are more characteristic of bulimia nervosa, not anorexia nervosa. A history of poor academic performance and mediocre achievements is not a typical assessment finding related to anorexia nervosa symptoms.
When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
A. Interview a family member instead.
B. Wait for the patient to answer the questions.
C. Remind the patient that you have other patients who need care.
D. Give the patient an assessment form listing the questions and a pen.
Correct answer:
When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.
When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
A. Interview a family member instead.
B. Wait for the patient to answer the questions.
C. Remind the patient that you have other patients who need care.
D. Give the patient an assessment form listing the questions and a pen.
Correct answer:
When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
B. Instruct the UAP not to wake the client under any circumstances during the night.
C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Correct answer:
By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.
A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?
A. Sitting quietly with the client
B. Telling the client that crying is not helpful
C. Suggesting that the client play a board game
D. Recommending how the client can change this situation
Correct answer:
The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?
A. "I don't remember anything about what happened to me."?
B. "I'd rather not talk about it right now."?
C. "It's the other entire guy's fault! He was going too fast."?
D. "My mother is heartbroken about this."?
Correct answer:
The correct answer is, '"I don't remember anything about what happened to me."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.
A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?
A. Suggest that the client arrange for help at home
B. Ask the client to describe her concerns more fully
C. Tell the client to speak to her primary health care provider about her concerns
D. Recommend that the client schedule times when family members can assist her
Correct answer:
When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.
Which approach would the healthcare provider use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?
A. Creating an anxiety-free environment for the client
B. Assisting the client with the development of healthy, adaptive coping mechanisms
C. Avoiding triggers that produce anxiety in the client
D. Providing reinforcement that the client's anxiety issues can be eliminated
Correct answer:
The healthcare provider would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the healthcare provider to help the client replace the ineffective worrying with effective, healthy coping mechanisms. Creating an anxiety-free environment is not feasible or recommended; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is important, avoiding all triggers that produce anxiety is often impractical. Providing reinforcement that anxiety issues can be eliminated is not appropriate as anxiety is a normal human experience that needs to be managed effectively rather than eliminated completely.
NCLEX-RN mental health practice questions, set 6 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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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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