NCLEX RN Questions on Psychiatric Nursing
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Question 1 of 5.
The friend of a client brought to the emergency department states, 'I guess she had some bad junk (heroin) today.' The client is drowsy and verbally nonresponsive. Which of the following assessment findings is of immediate concern to the nurse?
A. Respiratory rate of 9 breaths/minute.
B. Urinary retention.
C. Hypotension.
D. Reduced pupil size.
Explanation: A respiratory rate of 9 breaths/minute is of immediate concern, as heroin overdose can cause respiratory depression, posing a life-threatening risk requiring urgent intervention.
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.
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