Questions 74

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Mental Health RN NCLEX Questions Questions

Extract:


Question 1 of 5

A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply.

Correct Answer: A,B,C,E

Rationale: The nurse should advise maintaining contact with family and friends (
A), attending memorial services (
B), using relaxation and physical activities (
C), and attending community meetings (E) to support early recovery through social connection and coping. Public speaking (
D) may be premature and distressing in early stages.

Question 2 of 5

One evening the client takes the nurse aside and whispers, 'Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight.' Which of the following actions is the priority?

Correct Answer: D

Rationale: Explaining that the information must be shared immediately prioritizes safety, as the threat poses a serious risk to the hospital, requiring prompt reporting to ensure protection.

Question 3 of 5

A client known to have alcohol dependence is admitted to the emergency department with a temperature of 99°F, a pulse of 110, respirations of 26, and blood pressure of 150/98. The blood alcohol level is 0.25%, three times the legal limit. Now the client is becoming belligerent and uncooperative. In which order from first to last should the following nursing and medical orders be implemented?

Order the Items

Source Container

Administer lorazepam (Ativan) 2 mg I.M.
Draw blood for a magnesium level.
Take vital signs every 15 minutes.
Place client in a quiet room with dimmed lights.

Correct Answer: D, A, C, B

Rationale: The order is: 1) Place the client in a quiet room to reduce stimulation and agitation (
D). 2) Administer lorazepam to manage belligerence and withdrawal symptoms (
A). 3) Take vital signs every 15 minutes to monitor stability (
C). 4) Draw blood for magnesium level to assess electrolyte status (
B). This prioritizes de-escalation, symptom management, monitoring, and diagnostics.

Question 4 of 5

The nurse is advising a client with schizophrenia about what to do when she begins to get agitated. The client has been compliant with taking her medications and has worked with clinic staff on dealing with her illness and recognizing when she is becoming agitated. Indicate the order from first to last the nurse should suggest the following actions be taken.

Order the Items

Source Container

Take your oral lorazepam (Ativan).
Take your oral haloperidol (Haldol).
Remove yourself to a quiet environment.
Tell trusted people that you are becoming upset.

Correct Answer: C,D,A,B

Rationale: The nurse should suggest: 1) Remove to a quiet environment to reduce stimuli (
C); 2) Tell trusted people to seek support (
D); 3) Take lorazepam for immediate anxiety relief (
A); 4) Take haloperidol for longer-term symptom control (
B). This order prioritizes non-pharmacological interventions first, followed by medications based on their onset of action.

Question 5 of 5

A client commonly jumps when spoken to and reports feeling uneasy. The client says, 'It's as though something bad is going to happen.' In which order from first to last should the following nursing actions be done?

Order the Items

Source Container

Teach problem solving strategies.
Ask the client to deep breathe for 2 minutes.
Discuss the client's feelings in more depth.
Reduce environmental stimuli.

Correct Answer: D,B,C,A

Rationale: First reduce stimuli, then use deep breathing, discuss feelings, and finally teach problem-solving to manage anxiety.

Similar Questions

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother will be taken to the client. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families?
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The physician orders treatment with risperidone (Risperdal) to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which of the following?
The client with depression who is taking imipramine (Tofranil) states to the nurse, 'My doctor wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine.' Which response by the nurse is most appropriate?
A client is becoming agitated during a discussion: 'The client is the same, “I know that the nurse.' She leaves the group and goes to her room. Which action by the nurse is most therapeutic for the client?
During the third session with the nurse, a client who is being abused states, 'I don't know what to do anymore. He doesn't want me to go anywhere while he's at work, not even to visit my friends.' Which nursing diagnosis should the nurse formulate regarding this information?

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