A nurse is reviewing incident reports on a psychiatric unit and notes

NCLEX RN Questions on Psychiatric Nursing

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Question 1 of 5.

A nurse is reviewing incident reports on a psychiatric unit and notes an increase in client falls. Which of the following should be the nurse's first action to address this issue?

A. Increase staff-to-client ratio on the unit.

B. Implement a fall risk assessment protocol.

C. Provide in-service training on restraint use.

D. Install additional lighting in client rooms.

Explanation: Implementing a fall risk assessment protocol is the first step to identify at-risk clients and prevent falls, addressing the root cause. Increasing staff, training on restraints, or adding lighting are secondary and less directly tied to fall prevention without initial assessment.

Question 2 of 5.

The nurse is conducting an intake interview with an Asian American female who reports sadness, physical and mental fatigue, anxiety, and sleep disturbance. Prior to the client's time with the physician, it is important for the nurse to obtain information about the client's use of which of the following? Select all that apply.

A. Tea.

B. Herbal medicine.

C. Breathing exercise.

D. Massage.

E. Folk healer.

Explanation: Herbal medicine, breathing exercises, massage, and folk healers may impact treatment or interact with medications, requiring assessment.

Question 3 of 5.

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse is most therapeutic?

A. Wait for the client to begin the conversation.

B. Initiate contact with the client frequently.

C. Sit outside the client's room.

D. Question the client until he responds.

Explanation: Frequent initiation of contact shows care and encourages engagement without overwhelming the client.

Question 4 of 5.

During a group session, a client who is depressed tells the group that he lost his job. Which of the following responses by the nurse is best?

A. It must have been very upsetting for you.'

B. Would you tell us about your job.'

C. You'll find another job when you're better.'

D. You were probably too depressed to work.'

Explanation: Acknowledging the emotional impact validates the client's feelings and fosters therapeutic rapport.

Question 5 of 5.

A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his 'bowels have turned to jelly,' which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the physician. Which of the following should the nurse identify as a criterion for the client to be legally committable?

A. Evidence of psychosis.

B. Being gravely disabled.

C. Risk of harm to self or others.

D. Diagnosis of mental illness.

Explanation: Risk of harm to self or others is a primary criterion for involuntary commitment to ensure safety.