Psychiatric Mental Health Nursing NCLEX RN Questions
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Question 1 of 5.
Extract:The following scenario applies to the next 1 items The behavioral health nurse is caring for a 28-year-old client Item 1 of 1 Progress Notes 0914 – Nursing reports that the client required a PRN dose of diazepam after pacing the halls and shouting at the television despite failed redirect attempts. Mental Status Exam – Alert and disoriented to person, place, and situation; fair eye contact; unkempt appearance. Thought process was disorganized and illogical. The client denied A/V hallucinations and suicidal ideations. + delusions; thoughts of persecution stating, ‘someone is out to get me' while pointing to a television. Speech was disorganized, with a normal volume and a slightly increased rate. Insight and judgment are severely impaired.
Based on the physician's progress note, the client is in which phase of schizophrenia?
A. prodromal
B. acute
C. stabilization
D. maintenance
Explanation: Disorganized thoughts, delusions, and severe impairment indicate the acute phase of schizophrenia.
Question 2 of 5.
A client with schizophrenia completes a self-care task independently. Which response by the nurse is most appropriate?
A. You don't need help anymore.'
B. Great job! Let's try another task.'
C. Why didn't you do this before?'
D. I'll do the next task for you.'
Explanation: Praising the achievement and encouraging further tasks reinforces independence and builds confidence.
Question 3 of 5.
When conducting a mental status examination with a newly admitted client who has an Axis I diagnosis of paranoid schizophrenia, the client states, 'I'm being followed; it's not safe. They're monitoring my every move.' In which of the following areas of the mental status examination should be the mental status examined.
A. Thought content.
B. Quality of speech.
C. Insight.
D. Judgment.
Explanation: The client's statement reflects paranoid delusions, which are assessed under thought content in a mental status examination, as this area evaluates the presence of delusions or hallucinations.
Question 4 of 5.
A client who is suspicious of others including staff is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion and slow movements. Which goal should the nurse identify as the initial priority in the client's way?
A. Helping the client feel safe and accepted.
B. Introducing the client to other clients.
C. Giving the client information about the program.
D. Providing the client with clean, comfortable clothes.
Explanation: Establishing safety and acceptance is the priority for a suspicious client, as it builds trust and reduces paranoia, which is essential before addressing other needs like hygiene or socialization.
Question 5 of 5.
A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as indicating which of the following?
A. Delusion, requiring further assessment.
B. Unusual reaction to clozapine.
C. Expected adverse effect of clozapine.
D. Unresolved symptom of schizophrenia.
Explanation: Excessive salivation (sialorrhea) is a common side effect of clozapine, and the nurse should recognize it as an expected adverse effect rather than a delusion or symptom.
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