ATI RN
Mental Health Nursing Nclex Practice Questions Questions
Question 1 of 5
An emergency code was called after a patient pulled a knife from a pocket and threatened, 'I will kill anyone who tries to get near me.' The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient
Correct Answer: D
Rationale: The correct answer is D because the patient's action of pulling out a knife and making a threat demonstrated a clear and present danger to others. The patient's behavior posed an immediate risk to the safety of those around them, necessitating urgent intervention for the protection of others. A: While the patient was indeed threatening to others, the severity of the threat, involving a weapon, indicated a higher level of danger. B: Psychosis alone may not always indicate an immediate danger to others unless accompanied by specific threatening behavior. C: While escape risk is a consideration, the primary concern in this scenario was the patient's potential harm to others, justifying seclusion for safety reasons.
Question 2 of 5
An older adult is complaining of anxiety is prescribed diazepam (Valium) by a family physician. The physician asks the office nurse to explain the problematic side effects of this medication to the patient. Which instruction would be most important for the nurse to emphasize about this drug?
Correct Answer: D
Rationale: The correct answer is D: "You may feel dizzy and be prone to falls after taking this medication." Rationale: 1. Diazepam (Valium) is a benzodiazepine known to cause dizziness and drowsiness as common side effects. 2. Dizziness can increase the risk of falls, especially in older adults who may already have balance issues. 3. Falls can lead to serious injuries in older adults, making it crucial for the nurse to emphasize this risk. 4. Minor urine incontinence (choice A) is not a common side effect of diazepam. 5. Temporary memory disturbances (choice B) are possible but not as critical as the risk of falls. 6. Dependence (choice C) is a potential issue with benzodiazepines but may not be the most immediate concern in this scenario.
Question 3 of 5
A nurse is working with a family and using the Calgary Family Model. Problems have been identified, and the family being in which stage of the model?
Correct Answer: B
Rationale: The correct answer is B: Assessment. In the Calgary Family Model, the Assessment stage involves identifying and understanding the problems within the family system. This is where the nurse gathers information about the family's strengths, resources, and challenges. The nurse assesses the family's structure, communication patterns, roles, and interactions to develop a comprehensive understanding of the family dynamics. Engaging with the family (Choice A) occurs before the Assessment stage. Intervention (Choice C) comes after the Assessment stage when specific strategies are implemented. Termination (Choice D) is the final stage when the nurse concludes their work with the family.
Question 4 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 5 of 5
A client with schizophrenia is prescribed clozapine because other prescribed medications have been ineffective. After teaching the client and family about the drug, the nurse determines that the teaching was successful when they state which of the following?
Correct Answer: B
Rationale: The correct answer is B: "We'll need to make sure that he has his blood count checked at least weekly." Rationale: 1. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a severe decrease in white blood cells. 2. Monitoring blood counts weekly is crucial to detect early signs of agranulocytosis and intervene promptly. 3. Regular blood count monitoring allows for timely adjustments in medication dosage to prevent serious complications. Summary: A: Although monitoring the client's heart is important, regular electrocardiograms are not specifically required for clozapine. C: Smoking does affect clozapine levels, but this choice does not address the crucial need for blood count monitoring. D: Weight loss is a potential side effect of clozapine, but it is not the most critical monitoring parameter for this medication.