The nurse identifies a nursing diagnosis of Dressing or grooming self-

NCLEX RN Mental Health Questions

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Question 1 of 5.

The nurse identifies a nursing diagnosis of Dressing or grooming self-care deficit related to apathy, as evidenced by an inability to shower and dress herself for a female client diagnosed with schizophrenia. When planning care for this client, which of the following outcomes should the nurse expect the client to meet in a specified number of days?

A. Verbalize the need to shower and dress herself.

B. Recognize the need to shower and dress herself.

C. Explain reasons for showering and dressing herself.

D. Perform showering and dressing for herself.

Explanation: The outcome of performing showering and dressing addresses the self-care deficit directly, focusing on functional improvement, which is the goal of the nursing diagnosis.

Question 2 of 5.

The nurse is planning care with a Mexican American client who is diagnosed with depression. The client believes in 'mal ojo' (the evil eye), and uses treatment by a root healer. The nurse should do which of the following?

A. Avoid talking to the client about the root healer.

B. Explain to the client that Western medicine has a scientific, not mystical, basis.

C. Explain that such beliefs are superstitious and should be forgotten.

D. Involve the root healer in a consultation with the client, physician and nurse.

Explanation: Involving the root healer respects the client's cultural beliefs and facilitates a collaborative approach, enhancing trust and adherence to the treatment plan.

Question 3 of 5.

The nurse is reviewing the laboratory report with the client's lithium level taken that morning prior to administering the 5 p.m. dose of lithium. The lithium level is 1.8 mEq/L. The nurse should:

A. Administer the 5 p.m. dose of lithium.

B. Hold the 5 p.m. dose of lithium.

C. Give the client 8 oz (236 mL) of water with the lithium.

D. Give the lithium after the client's supper.

Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6â€“1.2 mEq/L), indicating potential toxicity, so the dose should be held and the physician notified.

Question 4 of 5.

After a few minutes of conversation, a female client who is depressed wearily asks the nurse, 'Why pick me to talk to? Go talk to someone else.' Which of the following replies by the nurse is best?

A. I'm assigned to care for you today, if you'll let me.'

B. You have a lot of potential, and I'd like to help you.'

C. I'll talk to someone else later.'

D. I'm interested in you and want to help you.'

Explanation: Expressing genuine interest validates the client's worth and fosters a therapeutic relationship.

Question 5 of 5.

A male client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which of the following nursing actions is most appropriate?

A. Explaining the importance of hygiene to the client.

B. Asking the client if he is ready to shower.

C. Waiting until the client's family can participate in the client's care.

D. Stating to the client that it's time for him to take a shower.

Explanation: Asking if the client is ready respects autonomy while gently encouraging hygiene, aligning with their energy level.

Related Questions

The client's friend reports that the client has been taking about eight 'reds' (800 mg of secobarbital [Seconal]) daily, besides drinking more alcohol than usual. The client's friend asks anxiously, 'Do you think she will live?' Which of the following responses by the nurse is most appropriate?

A client has been taking increased amounts of alprazolam (Xanax) for about 6 months for anxiety. She asks the nurse how she can 'get off the Xanax.' The most accurate answer by the nurse is which of the following?

A client is taking diazepam (Valium) for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply.

While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid?

A soldier is stationed in Iraq on his second tour of duty. His division was notified of the date they will be deployed to Afghanistan. As this date approaches, he is showing signs of excess anxiety and irritability and inability to sleep at night because of nightmares of IED (improvised explosive devices) tragedies, all leading to poor work performance. He is admitted to the base hospital for an evaluation. The admitting nurse should take the following actions in order of priority from first to last?