Appraise your knowledge with this 5-item Mental Health Nursing NCLEX Questions.
31. A depressed client on an inpatient unit says to the nurse, “My family would be better off without me.” What is the nurse’s best response?
a) “Have you talked to your family about this?”
b) “Everyone feels this way when they are depressed.”
c) “You will feel better once your medication begins to work.”
d) “You sound very upset. Are you thinking of hurting yourself?”
32. Mental Health Nursing NCLEX Questions about the nurse who has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time?
a) Initiate confinement measures.
b) Acknowledge the client’s behavior.
c) Assist the client to an area that is quiet.
d) Maintain a safe distance from the client.
33. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
a) The adolescent gives away a DVD and a cherished autographed picture of a performer.
b) The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room.
c) The adolescent becomes angry while speaking on the telephone and slams down the receiver.
d) The adolescent gets angry with her roommate when the roommate borrows the client’s clothes without asking.
34. The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action?
a) Administer an antianxiety agent.
b) Examine and treat the wound sites.
c) Secure and record a detailed history.
d) Encourage and assist the client to ventilate feelings.
35. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” How should the nurse interpret this behavior as a cue to modify the treatment plan?
a) Suggesting a reduction of medication
b) Allowing increased “in-room” activities
c) Increasing the level of suicide precautions
d) Allowing the client off-unit privileges as needed
Mental Health Nursing NCLEX Questions
Answers and Rationale
- Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options A, B, and C do not deal directly with the client’s feelings.
- Test-Taking Strategy: Note the strategic word best. Recalling therapeutic communication techniques will assist in directing you to the correct option. Option D is the only option that deals directly with the client’s feelings. In addition, clients at risk for suicide need to be assessed directly regarding the potential for self-harm.
- Rationale: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
- Mental Health Nursing NCLEX Questions Test-Taking Strategy: Focus on the strategic words least helpful. Also note the words aggressive behaviors and escalating. Recalling that the least restrictive measures should be used will direct you to the correct option.
- Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options B, C, and D deal with anger and acting-out behaviors that are often typical of any adolescent.
- Test-Taking Strategy: Eliminate options B, C, and D because they are comparable or alike. The correct option is different and is an action that could indicate that the client may be “saying goodbye.”
- Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options A, C, and D, may follow after the client has been treated medically.
- Test-Taking Strategy: Note the strategic word initial. Use Maslow’s Hierarchy of Needs theory to prioritize. Physiological needs come first. The correct option addresses the physiological need.
- Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
- Test-Taking Strategy: Focus on the subject, suicide precautions. Options A and D support the client’s notion that a cure has occurred. Option B allows the client to increase self-isolation self-isolation and would present a threat to the client’s safety. Knowing that safety is of the utmost importance will direct you to the correct option.
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Mental Health Nursing NCLEX Questions 36-40
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Mental Health Nursing NCLEX Questions 1-5
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