Mental Health NCLEX
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Question 1 of 5.
The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The client's spouse barges into the client's ED room with a gun and states “I'm going to kill you and anyone else who gets in my way.†Which action should be taken by the nurse initially?
A. Yell for help to distract the person's attention away from the client.
B. Firmly state “You don't want to hurt anyone else. Let's talk about it.â€
C. Use gestures to alert another nurse to clear others who may be nearby.
D. Use a nonaggressive posture and tone to state “Put the gun on the floor.â€
Explanation: Using a nonaggressive posture and tone (D) to request the gun be placed down de-escalates the situation safely. Yelling (A) may startle and escalate assuming intent (B) blocks communication and gesturing (C) risks escalation if noticed.
Question 2 of 5.
The nurse correctly informs the caller that most people have which physical signs after recent marijuana use? Select all that apply.
A. Shivering
B. Inflamed eyes
C. Rapid pulse
D. Restlessness
E. Pinpoint pupils
F. Increased sex drive
Explanation: Recent marijuana use commonly causes inflamed (red) eyes due to vasodilation, rapid pulse from cardiovascular stimulation, and restlessness from its psychoactive effects.
Question 3 of 5.
If a client is typical of other victims who remain in abusive relationships, what is the client most likely to believe?
A. The client is not in any serious danger.
B. The client can turn to the family for protection.
C. The client can prevent the battering behavior.
D. The client is free to leave the home at any time.
Explanation: Victims often believe they can control or prevent the abuse, reflecting denial or rationalization that keeps them in the abusive situation.
Question 4 of 5.
Which initial reaction would the nurse expect if the client is typical of others who just received news of this diagnosis?
A. Anger
B. Shock
C. Resentment
D. Depression
Explanation: Shock is the most common initial reaction to an HIV diagnosis, as it reflects the overwhelming and unexpected nature of the news.
Question 5 of 5.
Which assessment finding by the nurse is most suggestive to the obese client is taking dextroamphetamine (Dexedrine) at this time?
A. The client stares blankly into space.
B. The client monopolizes the discussions.
C. The client wears sunglasses indoors.
D. The client slurs words when speaking.
Explanation: Monopolizing discussions reflects the hyperactivity and talkativeness associated with stimulant use like dextroamphetamine.