Mental Health NCLEX Questions with Answers Graded A+
Quietly escort the patient to his room.
Encourage the patient to get dressed.
Explanation
• The nurse should take control of the situation without
A male patient in the psychiatric unit experiencing a state
causing the patient more anxiety. Walk the patient to his
of mania is walking the halls completely naked. How
room and encourage him to dress there.
should the nurse respond initially? (select all that apply)
• A manic patient often lacks good judgement and has
Quietly escort the patient to his room.
poor impulse control, but may respond well to non-threat-
Tell the patient he will be secluded if he does not get ening encouragement.
dressed.
• A manic patient is more receptive to non-threatening
Ask the other patients to go to their rooms. direction than confrontation, and walking with the patient
to his room and encouraging him to get dressed so that
Confront the patient and insist he get dressed. he can do something else he enjoys will get better results
than issuing an order.
Encourage the patient to get dressed.
• Confronting the patient or threatening the patient with
Withhold family visits due to inappropriate behavior. seclusion or restraint will often escalate the situation or
lead to resistance.
• Asking the other patients to return to their rooms is not
appropriate.
• Withholding visitation is not an appropriate response.
The home care nurse assesses an older adult client living
with adult children. The client is thin and frail, with bruis-
ing on the upper arms and back. Which circumstances
alert the nurse to an increased risk of abuse?
Select all that apply.
,The elderly client has a psychiatric diagnosis, such as
dementia or depression.
- The presence of any psychiatric diagnosis increases risk
of elder abuse.
The abuse of alcohol by the older adult client and/or a
family member in the home.
- Alcohol abuse increases risk of elder abuse.
Physical or cognitive impairment making the client depen-
dent on others for activities of daily living.
- Financial or physical dependence on others increases
the risk of elder abuse, in part because of the strain this
dependency puts on the family. The vulnerable older adult
may also feel unable to speak out against any mistreat-
ment they receive, beacuase they have nowhere else to
go.
Explanation
Elder neglect and abuse attects an estimated 2-10% of
adults, but is known to be under-reported. Nurses are
mandated to report known or suspected elder abuse to
Adult Protective Services or to law enforcement. Signs of
possible neglect or abuse include bruising, bilateral in-
juries, oversedation, weight loss, poor hygiene, depres-
sion, agitation, or withdrawal. Older adult clients are often
unable or scared to report abuse. Abusers have various
motivations including trying to get their "fair share," hav-
ing a history of using physical means to solve problems,
and other social, biomedical, relationship, and environ-
mental characteristics.
,Although lack of support system is a risk factor for elder
abuse, socioeconomic status alone does not correlate with
an increased risk.
Frequent ER visits do not increase risk of elder abuse, but
could be the outcome of abuse.
Otter a support person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
When providing care for a client who reports to the emer- • The nurse should otter an advocate from a local crisis
gency department immediately after a sexual assault, center to provide support, reassurance and resources. The
which nursing actions are appropriate? nurse should let the client know that she or he has the
Select all that apply. right to have a friend or family member present
Otter a support person or crisis advocate • The nurse should also provide care for and document any
injuries and notify local law enforcement.
Provide appropriate care for injuries
• Law enforcement should be immediately available in
Make the client sign the exam consent form case the client chooses to file a report or to transport the
evidence collection kit. Some states mandate reporting
Contact law enforcement any sexual assault, while other states only mandate report-
ing sexual assault for children or elders.
• In the emergency room, the nurse is responsible for
collecting evidence as well.
• A consent must be obtained from the client in order to
perform a sexual assault exam. The client should not be
, forced or pressured to consent to the exam, and adult
clients may decline to make a report to law enforcement.
• After emotional support is provided, the nurse will assist
with exam and collect specimens. The nurse should docu-
ment all objective evidence, including the client's physical
condition and statements.
Determine whether the sexual activity was consensual
• As a victim of sexual assault, the patient may be in a state
of shock or may have feelings of guilt or confusion about
the situation. It is never appropriate to question the client
about the assault or in any way imply that the client may
have been at fault.
Report this to the patient's provider.
Explanation
• The most correct response is the one that does not put
another nurse at risk and reports the incident so that the
patient's status can be assessed and addressed.
A crying post op patient is upset about the PCA being dis- • Asking another nurse to administer pain medication
continued and throws a meal tray when the nurse otters after this incident only puts the other nurse at risk. The
PO oxycodone. What is the most appropriate response? primary goal is patient and nurse safety followed by an
attempt to de-escalate (calm) the situation.
Put the patient in restraints.
• After invasive surgical procedures, many patients will
require IV pain medications. These patients are frequently
placed on PCA pumps for better pain control. When these
are discontinued, these patients can become anxious and
irritable because of discomfort and/or fear of increasing
pain.
Quietly escort the patient to his room.
Encourage the patient to get dressed.
Explanation
• The nurse should take control of the situation without
A male patient in the psychiatric unit experiencing a state
causing the patient more anxiety. Walk the patient to his
of mania is walking the halls completely naked. How
room and encourage him to dress there.
should the nurse respond initially? (select all that apply)
• A manic patient often lacks good judgement and has
Quietly escort the patient to his room.
poor impulse control, but may respond well to non-threat-
Tell the patient he will be secluded if he does not get ening encouragement.
dressed.
• A manic patient is more receptive to non-threatening
Ask the other patients to go to their rooms. direction than confrontation, and walking with the patient
to his room and encouraging him to get dressed so that
Confront the patient and insist he get dressed. he can do something else he enjoys will get better results
than issuing an order.
Encourage the patient to get dressed.
• Confronting the patient or threatening the patient with
Withhold family visits due to inappropriate behavior. seclusion or restraint will often escalate the situation or
lead to resistance.
• Asking the other patients to return to their rooms is not
appropriate.
• Withholding visitation is not an appropriate response.
The home care nurse assesses an older adult client living
with adult children. The client is thin and frail, with bruis-
ing on the upper arms and back. Which circumstances
alert the nurse to an increased risk of abuse?
Select all that apply.
,The elderly client has a psychiatric diagnosis, such as
dementia or depression.
- The presence of any psychiatric diagnosis increases risk
of elder abuse.
The abuse of alcohol by the older adult client and/or a
family member in the home.
- Alcohol abuse increases risk of elder abuse.
Physical or cognitive impairment making the client depen-
dent on others for activities of daily living.
- Financial or physical dependence on others increases
the risk of elder abuse, in part because of the strain this
dependency puts on the family. The vulnerable older adult
may also feel unable to speak out against any mistreat-
ment they receive, beacuase they have nowhere else to
go.
Explanation
Elder neglect and abuse attects an estimated 2-10% of
adults, but is known to be under-reported. Nurses are
mandated to report known or suspected elder abuse to
Adult Protective Services or to law enforcement. Signs of
possible neglect or abuse include bruising, bilateral in-
juries, oversedation, weight loss, poor hygiene, depres-
sion, agitation, or withdrawal. Older adult clients are often
unable or scared to report abuse. Abusers have various
motivations including trying to get their "fair share," hav-
ing a history of using physical means to solve problems,
and other social, biomedical, relationship, and environ-
mental characteristics.
,Although lack of support system is a risk factor for elder
abuse, socioeconomic status alone does not correlate with
an increased risk.
Frequent ER visits do not increase risk of elder abuse, but
could be the outcome of abuse.
Otter a support person or crisis advocate
Provide appropriate care for injuries
Contact law enforcement
Explanation
When providing care for a client who reports to the emer- • The nurse should otter an advocate from a local crisis
gency department immediately after a sexual assault, center to provide support, reassurance and resources. The
which nursing actions are appropriate? nurse should let the client know that she or he has the
Select all that apply. right to have a friend or family member present
Otter a support person or crisis advocate • The nurse should also provide care for and document any
injuries and notify local law enforcement.
Provide appropriate care for injuries
• Law enforcement should be immediately available in
Make the client sign the exam consent form case the client chooses to file a report or to transport the
evidence collection kit. Some states mandate reporting
Contact law enforcement any sexual assault, while other states only mandate report-
ing sexual assault for children or elders.
• In the emergency room, the nurse is responsible for
collecting evidence as well.
• A consent must be obtained from the client in order to
perform a sexual assault exam. The client should not be
, forced or pressured to consent to the exam, and adult
clients may decline to make a report to law enforcement.
• After emotional support is provided, the nurse will assist
with exam and collect specimens. The nurse should docu-
ment all objective evidence, including the client's physical
condition and statements.
Determine whether the sexual activity was consensual
• As a victim of sexual assault, the patient may be in a state
of shock or may have feelings of guilt or confusion about
the situation. It is never appropriate to question the client
about the assault or in any way imply that the client may
have been at fault.
Report this to the patient's provider.
Explanation
• The most correct response is the one that does not put
another nurse at risk and reports the incident so that the
patient's status can be assessed and addressed.
A crying post op patient is upset about the PCA being dis- • Asking another nurse to administer pain medication
continued and throws a meal tray when the nurse otters after this incident only puts the other nurse at risk. The
PO oxycodone. What is the most appropriate response? primary goal is patient and nurse safety followed by an
attempt to de-escalate (calm) the situation.
Put the patient in restraints.
• After invasive surgical procedures, many patients will
require IV pain medications. These patients are frequently
placed on PCA pumps for better pain control. When these
are discontinued, these patients can become anxious and
irritable because of discomfort and/or fear of increasing
pain.
