NCLEX RN Questions on Psychiatric Nursing
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Question 1 of 5.
A suicidal client is placed in the seclusion room and given lorazepam (Ativan) because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. Which of the following should the nurse do next?
A. Tell the client to stop doing that and act like a responsible adult.
B. Place the client in leather restraints.
C. Call the physician for additional medication orders.
D. Instruct a staff member to sit in the room with the client.
Explanation: Restraints are necessary to prevent immediate self-harm when other interventions fail.
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.