NCLEX-RN
NCLEX-RN Mental Health Questions
Extract:
Question 1 of 5
A 77-year-old client is brought to the emergency department by her son. The client is complaining to assess the number of the questions, 'I'm so worried about everything.' Her son says that she has heart failure and chronic schizophrenia. 'In addition to all of her heart medicines, she is on aripiprazole (Abilify), which was increased to 30 mg by her family doctor 3 days ago.' In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which of the following? Select all that apply.
Correct Answer: B,C,D
Rationale: Investigating schizophrenia symptoms (
B) assesses the need for aripiprazole; checking the dose (
C) is critical, as 30 mg is high for an elderly patient; and evaluating heart failure symptoms (
D) ensures medical stability, as aripiprazole can affect cardiac function.
Question 2 of 5
A client has been admitted to the emergency department with alcohol withdrawal delirium. At 9 a.m. on 10/25, the nurse notes that the client is confused. His vital signs are T=99°F, P=50, R=10, and BP=100/60. The nurse compares these findings to the nurses' progress notes from admission 24 hours ago. What should the nurse do first?
Correct Answer: C
Rationale: Attempting to arouse the client is the first action, as it assesses the level of consciousness and responsiveness, critical in determining the severity of delirium and guiding further interventions.
Question 3 of 5
After administering naloxone (Narcan), an opioid antagonist, the nurse should monitor the client carefully for which of the following?
Correct Answer: D
Rationale: Monitoring for respiratory depression is critical, as naloxone's effects may wear off before the opioid, potentially causing a recurrence of life-threatening respiratory issues.
Question 4 of 5
A client with dementia is disoriented to time. Which intervention should the nurse implement?
Correct Answer: B
Rationale: A large clock and calendar provide visual cues to help orient the client, reducing confusion.
Question 5 of 5
The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, 'Why isn't he eating? He's still talking about his food being poisoned.' Which of the following appraisals by the nurse is most accurate?
Correct Answer: A
Rationale: The wife's concern about her husband's refusal to eat due to delusions is reasonable, as it reflects a common symptom of paranoid schizophrenia that persists early in treatment.