NCLEX RN Mental Health Questions
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Question 1 of 5.
A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of his phenytoin (Dilantin) and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. The nurse should do the following in order of priority from first to last?
- A. Monitor the client's safety and place seizure pads on the cart rails.
- B. Record the time, duration and nature of the seizures.
- C. Page the ED physician and prepare to give diazepam (Valium) intravenously.
- D. Ask the friend about the client's medical history and current medications.
- A. Monitor the client's safety and place seizure pads on the cart rails.
- C. Page the ED physician and prepare to give diazepam (Valium) intravenously.
- B. Record the time, duration and nature of the seizures.
- D. Ask the friend about the client's medical history and current medications.
Correct arrangement
Explanation: First ensure safety with seizure pads, then prepare diazepam, record seizure details, and gather history.
Question 2 of 5.
The nurse is planning care with a Mexican American client who is diagnosed with depression. The client believes in 'mal ojo' (the evil eye), and uses treatment by a root healer. The nurse should do which of the following?
A. Avoid talking to the client about the root healer.
B. Explain to the client that Western medicine has a scientific, not mystical, basis.
C. Explain that such beliefs are superstitious and should be forgotten.
D. Involve the root healer in a consultation with the client, physician and nurse.
Explanation: Involving the root healer respects the client's cultural beliefs and facilitates a collaborative approach, enhancing trust and adherence to the treatment plan.
Question 3 of 5.
The nurse is reviewing the laboratory report with the client's lithium level taken that morning prior to administering the 5 p.m. dose of lithium. The lithium level is 1.8 mEq/L. The nurse should:
A. Administer the 5 p.m. dose of lithium.
B. Hold the 5 p.m. dose of lithium.
C. Give the client 8 oz (236 mL) of water with the lithium.
D. Give the lithium after the client's supper.
Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6–1.2 mEq/L), indicating potential toxicity, so the dose should be held and the physician notified.
Question 4 of 5.
After a few minutes of conversation, a female client who is depressed wearily asks the nurse, 'Why pick me to talk to? Go talk to someone else.' Which of the following replies by the nurse is best?
A. I'm assigned to care for you today, if you'll let me.'
B. You have a lot of potential, and I'd like to help you.'
C. I'll talk to someone else later.'
D. I'm interested in you and want to help you.'
Explanation: Expressing genuine interest validates the client's worth and fosters a therapeutic relationship.
Question 5 of 5.
A male client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which of the following nursing actions is most appropriate?
A. Explaining the importance of hygiene to the client.
B. Asking the client if he is ready to shower.
C. Waiting until the client's family can participate in the client's care.
D. Stating to the client that it's time for him to take a shower.
Explanation: Asking if the client is ready respects autonomy while gently encouraging hygiene, aligning with their energy level.
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