Questions 74

NCLEX-RN

NCLEX-RN Test Bank

Mental Health RN NCLEX Questions Questions

Extract:


Question 1 of 5

A client on a stretcher in the emergency department begins to thrash around, slap the sheets and yells, 'Get these bugs off of me.' She is disoriented and has a blood pressure of 189/75 and a pulse of 96. The friend who is with her says, 'She was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any.' The nurse should do the following in which order from first to last?

Correct Answer: B,E,D,A,F

Rationale: First implement observation, orient the client, monitor vital signs, administer medications, consider restraints if needed, and chart responses.

Question 2 of 5

A client who is depressed states, 'I'm an awful person. Everything about me is bad. I can't do anything right.' Which of the following responses by the nurse is most therapeutic?

Correct Answer: C

Rationale: Discussing specific accomplishments challenges negative self-perceptions and promotes cognitive restructuring.

Question 3 of 5

The nurse is assessing a 7-year-old boy with Tourette syndrome. Which of the following is a priority for the nurse to assess?

Correct Answer: A

Rationale: Multiple motor and verbal tics are hallmark symptoms of
Tourette syndrome, making them a priority for assessment.

Question 4 of 5

The client is feeling better as the symptoms of alcohol withdrawal abate. She refuses information about alcohol rehabilitation and states, 'I don't have a problem. I'll never drink like that again. I learned my lesson this time. I guess I'll just have to switch to beer or wine.' The nurse should respond by:

Correct Answer: C

Rationale: Urging her to attend Alcoholics Anonymous meetings is most appropriate, as it encourages ongoing support and addresses her denial, promoting long-term recovery.

Question 5 of 5

When conducting a mental status examination with a newly admitted client who has an Axis I diagnosis of paranoid schizophrenia, the client states, 'I'm being followed; it's not safe. They're monitoring my every move.' In which of the following areas of the mental status examination should be the mental status examined.

Correct Answer: A

Rationale: The client's statement reflects paranoid delusions, which are assessed under thought content in a mental status examination, as this area evaluates the presence of delusions or hallucinations.

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