NCLEX Mental Health Questions

Extract:

Question 1 of 5

If the nurse documents all of the following information in the database, which finding is probably the most significant source of conflict and anxiety for this client?

Correct Answer: A

Rationale: Forced retirement is a major life transition that can cause significant stress and anxiety due to loss of role and identity.

Question 2 of 5

The client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking shoving throwing items in the room and threatening staff. The charge nurse calls a behavioral situation code and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?

A. Have staff members who were harmed complete an incident report. B. Contact the health care provider to obtain an order for restraint use. C. Document the client’s behavior and action taken in the nurse’s notes. D. Check that the client’s wrist restraints are tightly secured to the HOB.

Correct Answer: B

Rationale: A physician or licensed independent practitioner must prescribe restraints and assess the client within 1 hour of restraint placement for client and staff safety. Incident reports (
A) follow treatment documentation (
C) follows HCP contact and securing restraints to the HOB (
D) risks circulation impairment.

Question 3 of 5

During a home visit, which assessment finding is most suggestive that the client is experiencing auditory hallucinations?

A. The client sings a song while walking around the room. B. The client quickly changes the topic of conversation. C. The client repeats a sentence over and over again. D. The client turns an ear as if listening to someone.

Correct Answer: D

Rationale: Turning an ear as if listening suggests the client is responding to auditory hallucinations, a common symptom in schizophrenia.

Question 4 of 5

The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding?

A. Poor coping mechanisms B. Physical pain from withdrawal C. A sense of guilt/shame regarding family D. Anxiety over lack of access to the substance of choice.

Correct Answer: D

Rationale: Anxiety from lack of substance access (
D) is the primary violence risk in withdrawal. Poor coping (
A) pain (
B) and guilt (
C) are secondary contributors.

Question 5 of 5

The nurse is teaching home health aides about monitoring for alcohol abuse in older adults. Which response by a home health aide indicates a need for further teaching?

A. “Alcohol abuse is the largest category of substance abuse problems in older adults.” B. “I should monitor more closely for alcohol abuse in single male clients who smoke.” C. “Retirement and freedom from work and family pressures tend to decrease alcohol use.” D. “Confusion malnutrition and self-neglect may be signs of alcohol abuse in the elderly.”

Correct Answer: C

Rationale: Retirement can increase alcohol use due to isolation (C is incorrect). Alcohol is a major issue (
A) risk factors include male smokers (
B) and signs include confusion (
D).

NCLEX Mental Health Questions | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN