mental health nclex questions
1. A male patient in the psychiatric unit experiencing a state of mania is
walking the halls completely naked. How should the nurse respond initially?
(select all that apply)
Quietly escort the patient to his room.
Tell the patient he will be secluded if he does not get dressed.
Ask the other patients to go to their rooms.
Confront the patient and insist he get dressed.
Encourage the patient to get dressed.
Withhold family visits due to inappropriate behavior.: Quietly escort the patient
to his room.
Encourage the patient to get dressed.
,Explanation
• The nurse should take control of the situation without causing the patient more
anxiety. Walk the patient to his room and encourage him to dress there.
• A manic patient often lacks good judgement and has poor impulse control, but may
respond well to non-threatening encouragement.
• A manic patient is more receptive to non-threatening direction than confrontation,
and walking with the patient to his room and encouraging him to get dressed so that
he can do something else he enjoys will get better results than issuing an order.
• Confronting the patient or threatening the patient with 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.
2. The home care nurse assesses an older adult client living with adult chil-
dren. The client is thin and frail, with bruising on the upper arms and back.
,Which circumstances alert the nurse to an increased risk of abuse?
Select all that apply.
Lower socioeconomic status of the older adult client's family.
The elderly client has a psychiatric diagnosis, such as dementia or depres-
sion.
The abuse of alcohol by the older adult client and/or a family member in the
home.
Physical or cognitive impairment making the client dependent on others for
activities of daily living.
Frequent emergency room visits for falls or unexplained illnesses.: 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 dependent 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 mistreatment they receive,
beacuase they have nowhere else to go.
Explanation
Elder neglect and abuse affects 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 injuries, oversedation, weight loss, poor hygiene,
depression, 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," having a history of using physical means to solve problems, and other social,
biomedical, relationship, and environmental characteristics.
1. A male patient in the psychiatric unit experiencing a state of mania is
walking the halls completely naked. How should the nurse respond initially?
(select all that apply)
Quietly escort the patient to his room.
Tell the patient he will be secluded if he does not get dressed.
Ask the other patients to go to their rooms.
Confront the patient and insist he get dressed.
Encourage the patient to get dressed.
Withhold family visits due to inappropriate behavior.: Quietly escort the patient
to his room.
Encourage the patient to get dressed.
,Explanation
• The nurse should take control of the situation without causing the patient more
anxiety. Walk the patient to his room and encourage him to dress there.
• A manic patient often lacks good judgement and has poor impulse control, but may
respond well to non-threatening encouragement.
• A manic patient is more receptive to non-threatening direction than confrontation,
and walking with the patient to his room and encouraging him to get dressed so that
he can do something else he enjoys will get better results than issuing an order.
• Confronting the patient or threatening the patient with 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.
2. The home care nurse assesses an older adult client living with adult chil-
dren. The client is thin and frail, with bruising on the upper arms and back.
,Which circumstances alert the nurse to an increased risk of abuse?
Select all that apply.
Lower socioeconomic status of the older adult client's family.
The elderly client has a psychiatric diagnosis, such as dementia or depres-
sion.
The abuse of alcohol by the older adult client and/or a family member in the
home.
Physical or cognitive impairment making the client dependent on others for
activities of daily living.
Frequent emergency room visits for falls or unexplained illnesses.: 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 dependent 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 mistreatment they receive,
beacuase they have nowhere else to go.
Explanation
Elder neglect and abuse affects 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 injuries, oversedation, weight loss, poor hygiene,
depression, 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," having a history of using physical means to solve problems, and other social,
biomedical, relationship, and environmental characteristics.
