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
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Show answer and rationale
Correct answer: B — The UAP auscultates the popliteal pulse with the cuff on the lower leg.
When obtaining blood pressure in the lower extremities, the popliteal pulse should be auscultated when the blood pressure cuff is applied around the thigh. The nurse should intervene when the UAP is auscultating the popliteal pulse with the cuff on the lower leg because this is incorrect placement. Option A, wrapping the cuff around the girth of the leg, ensures an accurate assessment. Option C, placing the client in a prone position, provides the best access to the artery. The systolic pressure in the popliteal artery is typically 10 to 40 mm Hg higher than in the brachial artery, so a systolic reading 20 mm Hg higher than the blood pressure in the client's arm is within the expected range and does not require intervention.
Question 2
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
A. The client is going through a grieving period.
B. The client talks as if another person is affected.
C. The client is willing to learn techniques to adapt.
D. The client recognizes the reality and becomes anxious.
Show answer and rationale
Correct answer: D — The client recognizes the reality and becomes anxious.
In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
Question 3
A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?
A. I'm sorry to hear that.'
B. 'Oh, you have a lot of good years left.'
C. 'You are concerned about your sex life?'
D. 'Have you asked your primary health care provider about that?'
Show answer and rationale
Correct answer: C — 'You are concerned about your sex life?'
The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.
Question 4
To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Show answer and rationale
Correct answer: D — Encourage frequent ambulation in the hallway.
To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
Question 5
A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
A. Administer anti-anxiety medications as prescribed by the healthcare provider
B. Engage in a conversation with the client regarding methods to enhance rest and sleep
C. Escort the client to a private room and stay with them
D. Review the client's medical history to determine previous treatment for these issues
Show answer and rationale
Correct answer: C — Escort the client to a private room and stay with them
The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
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Question 6
After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure.
Correct answer:
The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
Which intervention would the nurse implement to develop a caring relationship with the client's family?
A. Deciding health care options for the client
B. Identifying the client's family members and their roles
C. Declining to inform the client's family after performing a procedure
D. Refraining from discussing the client's health with the family
Correct answer:
To establish a caring relationship with the client's family, the nurse should start by identifying the family members and understanding their roles in the client's life. This step is crucial in determining how they can contribute to the client's healthcare and support. Deciding healthcare options for the client (Choice A) is not the nurse's role; it should be a collaborative decision with the client and family. Declining to inform the client's family after a procedure (Choice C) goes against transparency and collaboration in care. Refraining from discussing the client's health with the family (Choice D) can hinder effective communication and support, which are essential in developing a caring relationship with the family.
Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?
A. ''Tell me more about being Joan of Arc.''
B. 'We both know that you're not Joan of Arc.''
C. ''It seems like the world is a pretty scary place for you.''
D. 'You're safe here, because we won't let you be burned.''
Correct answer:
The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.
The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?
A. Encourage the use of diagnostic procedures.
B. Coordinate the use of folk treatments with ordered medical therapies.
C. Ask the patient to discontinue the cultural treatments during hospitalization.
D. Teach the patient that folk remedies will interfere with orders by the healthcare provider.
Correct answer:
The best action for the nurse is to coordinate the use of folk treatments with ordered medical therapies. Many culturally based therapies can complement Western treatments and medications. It is essential for the nurse to integrate both traditional folk treatments and Western therapies to provide holistic care. Some culturally based treatments can effectively complement Western medicine in treating diseases. Encouraging the patient to continue some culturally based treatments during hospitalization can enhance their overall well-being. Asking the patient to discontinue cultural treatments or teaching that folk remedies interfere with Western therapies may not align with the patient's beliefs and could hinder their care.
A client injured in a motor vehicle accident was brought to the emergency department and taken immediately for a scan. The client's family arrives and asks about the client's condition. Which response would the nurse provide?
A. Please do not worry; everything will be all right.
B. I am sorry; I do not have any information about the client.
C. You will have to wait for the primary health care provider.
D. Please wait; I will update you as soon as I have any information.
Correct answer:
In this situation, the most appropriate response for the nurse to provide to the client's family is to assure them that they will be updated as soon as there is relevant information available. This response not only acknowledges the family's concern but also demonstrates the nurse's commitment to keeping them informed. Option A, providing false reassurances, is not advisable as it may impact the family's ability to cope with potential bad news. Option B, stating that the nurse has no information, is not helpful and can cause distress. Option C, directing the family to the primary health care provider, is not ideal as the nurse should strive to communicate directly with the family to establish trust and provide support.
A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, 'That sounds gross. I don't think I can do it.' Which conclusion would the nurse make from this statement?
A. The client is unduly fastidious.
B. The client feels that having a baby is not that important.
C. The client may be uncomfortable with performing manual examination of the genitals.
D. The client is afraid that she is the cause of the infertility.
Correct answer:
The client's statement expressing discomfort with the procedure indicates a potential unease with performing a manual examination of her genitals. It is not uncommon for individuals to feel uncomfortable or anxious about such intimate procedures. The nurse should explore this further with the client to address any concerns or fears. The option stating that the client is unduly fastidious lacks evidence and is not supported by the client's statement. The assumption that the client does not value having a baby is not warranted based on the given statement. While self-blame is a common emotional response in cases of infertility, the client's statement does not directly suggest this as the primary concern in this scenario.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the healthcare provider about a sleeping pill.
Correct answer:
Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.
Which of the following individuals is at the highest risk of experiencing intimate partner violence?
A. A 36-year-old woman who is recently divorced
B. A 22-year-old man who is unemployed but living with friends
C. A 20-year-old woman who grew up with a psychologically abusive father
D. A 40-year-old man diagnosed with schizophrenia
Correct answer:
Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (A), unemployment (B), and schizophrenia diagnosis (D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.
A newly diagnosed client with human immunodeficiency virus (HIV) comments to the nurse, 'There are so many rotten people around. Why couldn't one of them get HIV instead of me?' Which statement is the nurse's best response?
A. 'I can understand why you are afraid of dying.'
B. 'It seems unfair that you contracted this disorder.'
C. 'Do you really wish this disorder on someone else?'
D. 'Have you thought of speaking with your religious adviser?'
Correct answer:
The client is expressing feelings of unfairness and questioning why they have HIV. The nurse's best response is to acknowledge the client's emotions. Choice B, 'It seems unfair that you contracted this disorder,' reflects empathy and validates the client's feelings, which can help them move towards acceptance. Choice A, 'I can understand why you are afraid of dying,' introduces the topic of death, which may not be the primary concern at this stage. Choice C, 'Do you really wish this disorder on someone else?' is judgmental and could induce guilt in the client. Choice D, 'Have you thought of speaking with your religious adviser?' deflects the conversation and does not address the client's current emotional needs.
What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?
A. "I see that you're worried. We're using medication to ease your wife's discomfort."?
B. "This is expected. I suggest that you go home because there's nothing you can do to help."?
C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification."?
D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."?
Correct answer:
The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.
NCLEX-RN mental health practice questions, set 9 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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