Psychiatric Mental Health Nursing NCLEX RN Questions
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Question 1 of 5.
Parents bring their 2-year old daughter into the emergency department after picking her up from her aunt's house. They are concerned that she has an upper respiratory infection. The nurse notices bruises on the patient's posterior thigh, wrists, and upper back. They appear to be in different stages of healing. Once the patient is stable after administering a bronchodilator and steroid, what should the nurse do?
A. Question the parents
B. Call the department of child and family services (DCFS)
C. Call poison control
D. Obtain an arterial blood gas (ABG)
Explanation: Bruises in various stages of healing on a 2-year-old in non-accidental areas (posterior thigh, wrists, upper back) suggest possible abuse. As a mandated reporter, the nurse must call DCFS (B) to report suspected abuse. Questioning parents (A) may be confrontational, poison control (C) is irrelevant, and ABG (D) is unnecessary for stable respiratory status.
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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