ATI RN
Mental Health Nursing Nclex Practice Questions Questions
Question 1 of 5
A son brings his father to the clinic and tells the nurse that his father has begun to act strangely in the past few days and has unprovoked outbursts of anger. After the incidents, the father expresses remorse for his outburst. The son says, 'I've never seen him act this way.' Which question would be most appropriate for the nurse to ask next?
Correct Answer: C
Rationale: The correct answer is C: "Has your father suffered any traumatic injury to his brain recently?" This question is most appropriate because sudden changes in behavior, unprovoked anger outbursts, and subsequent remorse could be indicative of a traumatic brain injury (TBI). TBIs can lead to various cognitive and emotional changes. It is crucial to investigate if there has been any recent head trauma that could explain the sudden behavioral changes. Choice A is incorrect because panic disorder typically presents with recurrent panic attacks and not necessarily unprovoked anger outbursts. Choice B is incorrect as it focuses on anger expression issues rather than potential brain injury. Choice D is incorrect as it only pertains to a recent physical injury to the head or neck, which may not necessarily explain the behavioral changes observed.
Question 2 of 5
A woman diagnosed with obsessive-compulsive disorder comes to the clinic with her husband. During the visit, the husband states, She's always checking and rechecking to make sure that all of the appliances are turned off before we go out. It's nerve-wracking. We can never get out of the house on time. Isn't checking once enough? An understanding of which of the following would the nurse need to incorporate into the response?
Correct Answer: B
Rationale: The correct answer is B: The client performs the ritual to relieve anxiety temporarily. In obsessive-compulsive disorder, repetitive behaviors such as checking are done to alleviate distress or anxiety, providing temporary relief. This behavior is a coping mechanism to manage overwhelming feelings of anxiety. The husband's observation of the wife's constant checking behavior indicates that she is engaging in this ritual to reduce her anxiety. Understanding this aspect is crucial for the nurse to provide appropriate support and interventions to help the client manage her symptoms effectively. Choice A (The client is attempting to exert control over the situation) is incorrect because the primary motivation behind compulsive behaviors in OCD is not about exerting control but rather reducing anxiety. Choice C (The woman's behavior reflects a need for safety) is incorrect as the main driver behind OCD behaviors is not necessarily related to safety concerns but rather to managing anxiety. Choice D (The woman is attempting to use thought stopping to decrease her behavior) is incorrect because thought stopping is a cognitive technique that is
Question 3 of 5
A nurse is preparing a plan of care for a client diagnosed with body dysmorphic disorder. Which nursing diagnosis would the nurse most likely identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image. This is the priority nursing diagnosis for a client with body dysmorphic disorder because it directly addresses the client's preoccupation and distress related to perceived flaws in appearance. By addressing the disturbed body image, the nurse can help the client work through these feelings and improve self-perception. Choice B: Ineffective Coping may be relevant but addressing the underlying body image distortion is crucial. Choice C: Low Self-Esteem is a common issue with body dysmorphic disorder but improving body image perception is more specific. Choice D: Risk for Other-Directed Violence is not directly related to body dysmorphic disorder symptoms. In summary, addressing the core issue of distorted body image is the priority in caring for a client with body dysmorphic disorder.
Question 4 of 5
The nurse is assessing a 78-year-old client who lives alone in his own home. To assess the client's instrumental activities of daily living, which question would be most appropriate to ask?
Correct Answer: D
Rationale: The correct answer is D because assessing the client's ability to go to the store and buy groceries directly evaluates their instrumental activities of daily living (IADLs), which are crucial for independent living. This question helps determine the client's mobility, cognitive function, and ability to manage finances and nutrition. Choices A and B focus more on basic activities of daily living (ADLs) related to personal hygiene and clothing changes. Choice C is related to cooking meals, which is also an IADL but may not provide as comprehensive information about the client's overall independence compared to the ability to shop for groceries.
Question 5 of 5
A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment?
Correct Answer: A
Rationale: The correct answer is A: Danger Assessment Screen. This tool is specifically designed to assess the risk of lethality in individuals who have experienced abuse. It includes questions related to the severity and frequency of abuse, as well as other risk factors such as access to weapons and history of threats. It helps identify clients at high risk of harm or death. B: Abuse Assessment Screen is a screening tool to identify abuse but does not specifically focus on lethality risk. C: Burgess-Partner Abuse Scale is a measure of the frequency and severity of intimate partner violence, but it does not assess lethality risk. D: Beck Depression Inventory is a tool to assess the severity of depression and is not designed to evaluate the risk of harm or death in abuse survivors.