Mental Health NCLEX Questions with Rationale

Extract:

Question 1 of 5

The nurse is counseling the client with a substance abuse disorder. Which defense mechanism is the nurse most likely to observe the client using in response to a stressful event?

Correct Answer: B

Rationale: Regression (
B) is common in substance abuse showing childlike behaviors. Repression (
A) sublimation (
C) and reaction formation (
D) are less typical.

Question 2 of 5

Which findings strongly suggest that the client is experiencing an exacerbation of the bipolar disorder? Select all that apply.

A. The client has been spending money extravagantly. B. The client has been avoiding social activities. C. The client has been methodically cleaning the house. D. The client has been staying up late to read. E. The client demonstrates increased sexual promiscuity. F. The client has increased anxiety when going outside the house.

Correct Answer: A,E

Rationale: Extravagant spending and sexual promiscuity are indicative of mania, a key feature of bipolar disorder exacerbation.

Question 3 of 5

The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?

A. Allow the parent to enter the room and see the child. B. Tell the parent that the HCP wants to speak with the parent first. C. Contact Social Services to report the parent’s abusive behavior. D. Initiate the emergency response system for behavioral situations.

Correct Answer: D

Rationale: Initiating the emergency response (
D) ensures safety. Allowing entry (
A) deferring to HCP (
B) or reporting to Social Services (C likely already done) are inappropriate.

Question 4 of 5

The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.

A. The client reports being unable to move the right hand. B. The client's fingers and toes are pale. C. The client reports having pain. D. Capillary refill is greater than 6 seconds. E. There is excoriation around the wrist. F. The client reports numbness and tingling.

Correct Answer: B,D,F

Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.

Question 5 of 5

What is the most appropriate nursing action when the terminally ill client's death is imminent?

A. Stay with the client and contact the family. B. Notify the hospital chaplain of the potential for death. C. Call the funeral home, alerting them of an imminent death. D. Transfer the client to the intensive care unit.

Correct Answer: A

Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.

Mental Health NCLEX Questions with Rationale | Nurselytic

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