A client with dementia who prefers to stay in his room has been brough

NCLEX RN Mental Health Questions

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Question 1 of 5.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client?

A. There is only one other client in the dayroom; the rest are in a group session in another room.

B. There are three staff members and one physician in the nurse's station working on charting.

C. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.

D. The room is brightly lit with fluorescent lights.

Explanation: Conflicting stimuli, such as a relaxation tape and a crime show on TV, can overwhelm a client with dementia, causing agitation due to difficulty processing multiple inputs.

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 (0.6â€“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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