When considering the pathophysiology responsible for both delirium and dementia, which intervention is appropriate for delirium specifically?

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Nclex Mental Health Practice Questions Questions

Question 1 of 9

When considering the pathophysiology responsible for both delirium and dementia, which intervention is appropriate for delirium specifically?

Correct Answer: B

Rationale: The correct answer is B: Monitor neurological status on an ongoing basis. Delirium is characterized by acute changes in cognition and attention, necessitating continuous monitoring of neurological status to detect any fluctuations or worsening. This allows for prompt intervention and management to prevent complications. A: Assisting with basic needs is important but not specific to delirium management. C: Placing an identification bracelet does not directly address the cognitive changes seen in delirium. D: Giving simple directions is helpful, but monitoring neurological status is more crucial for managing delirium.

Question 2 of 9

When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient?

Correct Answer: A

Rationale: The correct answer is A: Change of shift report. During this time, vital patient information is transferred between nurses, making it crucial to be alert to communication errors. Patient safety relies on accurate and clear communication. Other choices (B, C, D) involve important communication opportunities, but the handover of information during shift change is when critical details can be missed or misunderstood, leading to potential harm. It is essential for nurses to focus on effective communication during this transition to ensure continuity of care and patient safety.

Question 3 of 9

A nurse in an inpatient setting formulates an outcome for a client who has a nursing diagnosis of altered social interaction R/T paranoid thinking AEB aggressive behaviors. Which initial, correctly written outcome would the nurse expect the client to achieve?

Correct Answer: C

Rationale: Rationale: C is correct because it focuses on addressing the nursing diagnosis of altered social interaction due to paranoid thinking. Listing triggers to angry outbursts shows an understanding of personal patterns and promotes self-awareness. This outcome aligns with the client's current state and is measurable within a specific timeframe. Summary of other choices: A: This choice is incorrect as it does not address the specific issue of paranoid thinking and aggressive behaviors. B: While adaptive coping strategies are important, this choice does not directly target the altered social interaction aspect of the nursing diagnosis. D: Walking away from confrontation may be a coping strategy, but it does not address the underlying issue of paranoid thinking and altered social interaction.

Question 4 of 9

A couple is concerned that the husband's father may be developing depression. In questioning the couple, which of the following statements would support their concern?

Correct Answer: C

Rationale: Step 1: The correct answer is C because it indicates a prolonged period of over 2 months of persistent symptoms such as crying, inability to eat or sleep. Step 2: This prolonged duration of symptoms is indicative of a potential depressive episode. Step 3: The inability to eat or sleep are common symptoms of depression. Step 4: This statement highlights a significant change in the father's behavior following the mother's death, suggesting a possible depressive disorder. Summary: Choice A: The duration of symptoms is not as prolonged as in choice C. Choice B: While agitation and anxiety can be symptoms of depression, they are not as specific or severe as the symptoms in choice C. Choice D: The timeframe of symptoms mentioned here is not as long as in choice C, making it less concerning for depression.

Question 5 of 9

The nurse is assessing a client who is diagnosed with borderline personality disorder. Which client statement indicates the client is at risk for self-injurious behavior?

Correct Answer: D

Rationale: The correct answer is D because impulsivity is a common characteristic of borderline personality disorder and can lead to self-injurious behaviors. The statement "It is almost as if as soon as I think of doing something, I immediately do it" indicates a lack of impulse control and potential for engaging in harmful behaviors without considering consequences. A: This statement expresses feelings of depression but does not directly indicate self-injurious behavior risk. B: This statement suggests a lack of autonomy but does not directly indicate self-injurious behavior risk. C: This statement describes dissociation, which is common in borderline personality disorder but does not directly indicate self-injurious behavior risk. In summary, choice D is the correct answer as it directly implies impulsivity and potential for self-injurious behavior, while the other choices do not clearly indicate this risk.

Question 6 of 9

A 73-year-old man was diagnosed with a serious mental illness at age 20. Subsequently, he was frequently hospitalized. Two years ago, he was transferred to a group home. When considering the effects of institutionalization, which behavior demonstrates adaptation to the new environment?

Correct Answer: C

Rationale: The correct answer is C: Makes himself lunch when he is hungry. This behavior demonstrates adaptation to the new environment as it shows independence and self-care skills. Choosing to prepare a meal when hungry indicates the individual is adjusting to living in the group home by taking care of his basic needs. Options A, B, and D are not necessarily indicative of adaptation to the new environment as they could be influenced by external factors or personal preferences without necessarily reflecting effective adjustment to the group home setting.

Question 7 of 9

A nurse is working with a client who is a survivor of violence on developing a safety plan. Which of the following would the nurse address first?

Correct Answer: B

Rationale: The correct answer is B, recognizing the signs of danger, as it is crucial to be able to identify potential threats before devising an escape plan or identifying safe places. By recognizing signs of danger, the client can proactively assess risky situations and take necessary precautions. This step is vital in ensuring the client's safety and preventing harm. Option A, devising an escape route, would be ineffective if the client cannot recognize the signs of danger to know when to use the route. Option C, identifying a safe place to hide, is not as effective as recognizing signs of danger since hiding may not always be a viable solution. Option D, identifying a signal to indicate it is safe to leave, would not be effective if the client cannot accurately assess when it is safe to leave. Recognizing signs of danger is the foundational step in creating a comprehensive safety plan.

Question 8 of 9

A nurse is developing a teaching plan for a client with schizophrenia. Which method would the nurse use to be most effective?

Correct Answer: B

Rationale: The correct answer is B because having the client write down information after being directly given the correct information is most effective for clients with schizophrenia. This method helps reinforce learning through repetition and aids memory retention. Writing down information also allows the client to refer back to it for reinforcement. A: Engaging the client in trial and error learning can be frustrating and overwhelming for someone with schizophrenia, leading to confusion. C: Asking the client to guess at the correct answer may increase anxiety and decrease confidence, which can hinder the learning process. D: Using colorful visual aids may be distracting and overwhelming for a client with schizophrenia, making it harder to focus on the information being presented.

Question 9 of 9

The nurse is counseling a family with a 10-year-old child after the death of a favorite uncle. The nurse provides guidance to the parents, informing them that the child may exhibit which of the following as a response?

Correct Answer: B

Rationale: The correct answer is B because children often express grief through physical symptoms like aches and pains. This is known as somatic complaints. Children may find it difficult to articulate their emotions verbally, so physical symptoms may manifest instead. Option A is incorrect as talking about scary novels is not a common response to grief in children. Option C is incorrect as fear of leaving home is more associated with separation anxiety. Option D is incorrect as becoming obsessed with religious rituals is not a typical response to grief in children.

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