NCLEX - W14 - Mental Health I

Question 1

1. A client states, “I can’t sleep. I stay up all night worrying about my job.” Which response by the nurse demonstrates the therapeutic communication technique of restating?
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   a. “You are having difficulty sleeping because you are worried about your job.”
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   b. “You are saying that you can’t sleep because you are worrying about your job.”
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   c. “It sounds like you are having a lot of stress related to your job.”
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   d. “Have you tried any relaxation techniques to help you sleep?”

Answer 1

b. “You are saying that you can’t sleep because you are worrying about your job.”

Rationale: Restating involves repeating the main idea of what the client has said to confirm understanding.
Option B accurately reflects the client’s statement.

Question 2

A client with a history of anxiety tells the nurse, “I’m so nervous about this surgery. What if something goes wrong?” Which nursing response demonstrates false reassurance?
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a. “Tell me more about your concerns related to the surgery.”
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b. “It’s normal to feel anxious before surgery. Let’s talk about some ways to manage your anxiety.”
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c. “Don’t worry, everything will be fine. You are in good hands.”
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d. “I understand that you are feeling anxious. Have you ever had surgery before?”

Answer 2

c. “Don’t worry, everything will be fine. You are in good hands.”

Rationale: False reassurance offers empty promises and minimizes the client’s feelings. Option C dismisses the client’s fears.

Question 3

The nurse is caring for a client who is withdrawn and isolates themself in their room. Which nursing action is most likely to promote trust with this client?
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a. Explaining the importance of socializing with other clients.
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b. Challenging the client’s decision to isolate.
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c. Spending short, frequent periods of time with the client, offering simple activities.
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d. Leaving the client alone to respect their need for privacy.

Answer 3

c. Spending short, frequent periods of time with the client, offering simple activities.

Rationale: Clients with low self-esteem or social anxiety may find it difficult to engage in social situations. Spending short, frequent periods with the client and offering simple activities can gradually build trust and encourage interaction without feeling overwhelming.

Question 4

A client on a psychiatric unit tells the nurse, “The voices are telling me to hurt myself.” Which nursing response is a priority?
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a. “I understand that you are hearing voices. I will stay with you for a while.”
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b. “The voices are not real. Try to ignore them.”
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c. “Why do you think the voices are telling you to hurt yourself?”
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d. “Have you ever heard these voices before?”

Answer 4

a. “I understand that you are hearing voices. I will stay with you for a while.”

Rationale: The priority is to ensure the client’s safety. Staying with the client and offering reassurance provides immediate support and demonstrates the nurse’s commitment to their well-being

Question 5

A client with depression tells the nurse, “I’m worthless. I don’t deserve to be happy.” Which nursing response demonstrates the therapeutic communication technique of reflecting?
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a. “Everyone deserves to be happy, including you.”
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b. “It’s the depression talking. You are not worthless.”
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c. “You are feeling worthless and like you don’t deserve to be happy?”
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d. “Let’s talk about some positive qualities that you have.”

Answer 5

c. “You are feeling worthless and like you don’t deserve to be happy?”

Rationale: Reflecting involves directing the client’s feelings back to them for acknowledgment and validation. Option C accurately mirrors the client’s expressed emotions.

Question 6

Which of the following is an example of a client’s right to the least restrictive environment?
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a. A client is placed in seclusion because they are yelling obscenities at the staff.
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b. A client who is pacing and agitated is offered PRN medication before being placed in restraints.
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c. A client who is suicidal is placed on one-to-one observation rather than being placed in restraints.
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d. A client who is paranoid and refusing to leave their room is forced to attend group therapy.

Answer 6

c. A client who is suicidal is placed on one-to-one observation rather than being placed in restraints.

Rationale: The least restrictive environment ensures that clients receive the necessary care while preserving their freedom to the greatest extent possible. One-to-one observation provides safety monitoring without resorting to restraints

Question 7

A client diagnosed with schizophrenia tells the nurse, “My food is poisoned. I won’t eat it.” Which nursing intervention is most appropriate?
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a. Arguing with the client about the reality of their delusion.
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b. Forcing the client to eat because they are refusing food.
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c. Ignoring the client’s delusional statement to avoid reinforcing it.
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d. Offering the client pre-packaged food from the vending machine to address their fear.

Answer 7

d. Offering the client pre-packaged food from the vending machine to address their fear.

Rationale: Clients experiencing delusions often interpret their environment through a distorted lens. Addressing their fear by offering a safe alternative acknowledges their feelings and promotes trust without challenging their belief system.

Question 8

Which of the following client behaviors should the nurse document as objective data?
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a. The client is feeling anxious about their upcoming surgery.
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b. The client is pacing back and forth in the hallway and talking rapidly.
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c. The client is experiencing auditory hallucinations.
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d. The client is angry at their family for not visiting them.

Answer 8

b. The client is pacing back and forth in the hallway and talking rapidly.

Rationale: Objective data are observable and measurable. Option B describes the client’s behavior in a factual and observable manner.

Question 9

A client who is depressed and withdrawn states, “I don’t want to go to group therapy. It’s pointless.” Which nursing response is most likely to encourage the client’s participation?
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a. “It’s important for you to go to group therapy. It will help you feel better.”
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b. “I understand that you don’t feel like going, but group therapy can offer a chance to connect with others who might understand what you’re going through.”
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c. “Why don’t you want to go to group therapy?”
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d. “You are just isolating yourself, and that’s not going to help your depression.”

Answer 9

b. “I understand that you don’t feel like going, but group therapy can offer a chance to connect with others who might understand what you’re going through.”

Rationale: Acknowledging the client’s feelings and then highlighting the potential benefits of group therapy, such as connecting with others, is more likely to encourage participation than authoritative directives.

Question 10

The nurse is caring for a client who is experiencing a panic attack. The client is hyperventilating, diaphoretic, and reports feeling like they are having a heart attack. Which nursing intervention is a priority?
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a. Leaving the client alone to calm down.
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b. Staying with the client and coaching them in deep breathing exercises.
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c. Administering an antianxiety medication as ordered.
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d. Attempting to engage the client in a discussion about their stressors.

Answer 10

b. Staying with the client and coaching them in deep breathing exercises.

Rationale: During a panic attack, the client’s physiological symptoms require immediate attention. Staying with the client and assisting them in deep breathing techniques can help regulate their breathing pattern and reduce anxiety.

Question 11

Which statement by the nurse demonstrates an understanding of the concept of genuineness in therapeutic communication?
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a. “I always try to be friendly and cheerful with my clients, even when I am having a bad day.”
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b. “It’s important to be honest with clients, even if it means telling them things they don’t want to hear.”
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c. “I try to be myself when I am interacting with clients and let my personality show through.”
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d. “I never share personal information with clients, even if they ask me about my life.”

Answer 11

c. “I try to be myself when I am interacting with clients and let my personality show through.”

Rationale: Genuineness involves being authentic and transparent in interactions with clients while maintaining professional boundaries. Option C reflects this concept.

Question 12

A client with obsessive-compulsive disorder tells the nurse that they wash their hands 100 times a day. The nurse responds, “That must be very tiring.” Which nontherapeutic communication technique is the nurse demonstrating?
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a. Minimizing
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b. Requesting an explanation
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c. Making a stereotyped comment
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d. Giving advice

Answer 12

c. Making a stereotyped comment

Rationale: The nurse’s response is a cliché and offers no meaningful contribution to the interaction.

Question 13

The nurse observes that a client with paranoia is sitting alone in a corner of the day room, staring suspiciously at other clients. Which nursing action is most likely to promote interaction?
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a. Ignoring the client’s behavior to avoid drawing attention to them.
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b. Forcing the client to participate in a group activity.
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c. Approaching the client and inviting them to join a simple, structured activity, such as a card game.
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d. Asking the client why they are so paranoid and suspicious of others.

Answer 13

c. Approaching the client and inviting them to join a simple, structured activity, such as a card game.

Rationale: Clients with paranoia are often distrustful and anxious in social settings. Offering a simple, structured activity provides a safe and predictable way to engage without feeling overwhelmed.

Question 14

Which of the following client statements indicates that the termination phase of the therapeutic relationship is not going well?
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a. “I’m going to miss talking to you every week.”
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b. “I feel like I’ve made a lot of progress in therapy.”
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c. “I don’t think I’m ready to be discharged yet. I still need your help.”
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d. “I’m looking forward to using the coping skills I’ve learned.”

Answer 14

c. “I don’t think I’m ready to be discharged yet. I still need your help.”

Rationale: Difficulty accepting the termination of the therapeutic relationship can indicate that the client is struggling with separation and independence. Option C reflects this struggle

Question 15

A client asks the nurse, “What should I do about my marriage? I don’t know whether to stay or leave.” Which nursing response is most appropriate?
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a. “I think you should leave your spouse. They are not treating you well.”
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b. “If I were you, I would stay in the marriage and try to work things out.”
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c. “That’s a difficult decision. What are some of your thoughts and feelings about your options?”
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d. “Have you tried couples counseling?”

Answer 15

c. “That’s a difficult decision. What are some of your thoughts and feelings about your options?”

Rationale: Offering advice undermines the client’s autonomy and can foster dependence. Option C encourages the client to explore their own feelings and make their own decisions.

Question 16

Which of the following are examples of a nurse breaching professional boundaries? (Select all that apply.)
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a. Accepting a $100 gift card from a grateful client upon discharge.
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b. Offering to pray with a client who requests spiritual support.
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c. Sharing personal relationship problems with a client.
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d. Contacting a client on social media after they are discharged.
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e. Attending a client’s graduation ceremony after they are discharged.

Answer 16

a. Accepting a $100 gift card from a grateful client upon discharge.
c. Sharing personal relationship problems with a client.
d. Contacting a client on social media after they are discharged.

Rationale: Professional boundaries are essential for maintaining the integrity of the nurse-client relationship. Accepting expensive gifts, disclosing personal information, and engaging in social contact outside of the therapeutic context are examples of boundary violations.

Question 17

Which of the following are important components of the nurse’s self-awareness in the therapeutic relationship? (Select all that apply.)
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a. Recognizing personal biases and prejudices.
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b. Identifying personal values and beliefs.
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c. Understanding how personal experiences can influence interactions with clients.
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d. Sharing personal opinions with clients to build rapport.
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e. Becoming emotionally involved in the client’s problems.

Answer 17

a. Recognizing personal biases and prejudices.
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b. Identifying personal values and beliefs.
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c. Understanding how personal experiences can influence interactions with clients.

Rationale: Self-awareness is crucial for maintaining objectivity and therapeutic boundaries in the nurse-client relationship. Recognizing biases, values, and the influence of personal experiences helps ensure that the nurse’s actions are client-centered and ethical.

Question 18

A client is being discharged from an acute care psychiatric unit after stabilization of their manic symptoms. Which community resource would be most appropriate for referral?
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a. A homeless shelter
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b. A support group for individuals with bipolar disorder
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c. An intensive outpatient program (IOP)
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d. A long-term care facility

Answer 18

c. An intensive outpatient program (IOP)

Rationale: An IOP provides structured support and treatment for clients transitioning from inpatient care to the community. It offers therapy, medication management, and skills training to help clients maintain stability.

Question 19

Which of the following statements about the right to refuse treatment is true?
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a. All clients have the absolute right to refuse any treatment, even if it is life-saving.
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b. Clients generally have the right to refuse treatment, but there are exceptions in cases of emergency or when they are deemed incompetent to make decisions.
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c. Only clients who are voluntarily admitted to a psychiatric unit have the right to refuse treatment.
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d. Clients who refuse treatment are always considered noncompliant and may be discharged against medical advice.

Answer 19

b. Clients generally have the right to refuse treatment, but there are exceptions in cases of emergency or when they are deemed incompetent to make decisions.

Rationale: While clients generally have the right to refuse treatment, exceptions exist in situations where their refusal could result in harm to themselves or others, or when they lack the capacity to make informed decisions.

Question 20

A client with a history of depression tells the nurse, “I don’t think I can go on anymore. I just want it all to end.” Which initial nursing action is most appropriate?
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a. Changing the subject to distract the client from their thoughts.
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b. Offering reassurance that things will get better.
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c. Assessing the client’s suicide risk, including any plans or intent.
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d. Telling the client that they should be grateful for what they have in their life.

Answer 20

c. Assessing the client’s suicide risk, including any plans or intent.

Rationale: When a client expresses suicidal thoughts, the priority is to assess their level of risk. This involves determining the seriousness of their intent, any specific plans, and the availability of means.

Question 21

The nurse is preparing to teach a group of clients about stress management techniques. Which of the following techniques should be included? (Select all that apply.)
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a. Deep breathing exercises
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b. Substance use avoidance
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c. Progressive muscle relaxation
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d. Thought-stopping
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e. Mindfulness meditation

Answer 21

a. Deep breathing exercises
c. Progressive muscle relaxation
e. Mindfulness meditation

Rationale: Deep breathing exercises, progressive muscle relaxation, and mindfulness meditation are all effective stress management techniques that promote relaxation and reduce anxiety.

Question 22

A client tells the nurse, “I am so stressed out about my divorce. I can’t eat or sleep.” The nurse recognizes that the client is experiencing which level of anxiety?
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a. Mild
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b. Severe
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c. Moderate
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d. Panic

Answer 22

b. Severe

Rationale: Severe anxiety is characterized by significant distress and impairment in functioning, often manifesting in physical symptoms such as sleep disturbances and appetite changes.

Question 23

A client with generalized anxiety disorder asks the nurse, “Why am I so anxious all the time?” Which nursing response is most accurate?
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a. “It’s because you are not trying hard enough to relax.”
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b. “It’s all in your head. You just need to think positive thoughts.”
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c. “Anxiety is a complex condition that can be caused by a combination of genetic, biological, and environmental factors.”
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d. “You probably just need to take a vacation and get away from it all.”

Answer 23

c. “Anxiety is a complex condition that can be caused by a combination of genetic, biological, and environmental factors.”

Rationale: Anxiety disorders are multifactorial in nature, involving a complex interplay of genetic predispositions, biological vulnerabilities, and environmental triggers. Option C accurately reflects this understanding.

Question 24

Which nursing intervention is most effective in helping a client who is experiencing auditory hallucinations?
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a. Arguing with the client about the reality of their hallucinations.
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b. Ignoring the hallucinations and focusing on other topics.
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c. Isolating the client to prevent them from disturbing others.
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d. Acknowledging the client’s experience and offering reassurance and support.

Answer 24

d. Acknowledging the client’s experience and offering reassurance and support.

Rationale: Clients experiencing hallucinations are often frightened and distressed. Acknowledging their experience without judgment and offering support creates a safe and therapeutic environment.

Question 25

25. A client with obsessive-compulsive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI) medication. Which statement by the client indicates that they understand the medication teaching?
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    a. “This medication will cure my OCD.”
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    b. “I will start feeling better right away after I take the first dose.”
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    c. “It may take several weeks for this medication to reach its full effect.”
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    d. “I don’t need to worry about any side effects from this medication.”

Answer 25

c. “It may take several weeks for this medication to reach its full effect.”

Rationale: SSRIs are commonly used to treat OCD, but they take several weeks to reach their therapeutic effect. It’s crucial for the client to understand this to manage expectations and encourage adherence.

Question 26

The nurse is conducting a mental status examination on a new client. Which of the following areas should be assessed? (Select all that apply.)
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a. Appearance
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b. Mood and affect
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c. Past medical history
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d. Thought processes
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e. Cognition

Answer 26

a. Appearance
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b. Mood and affect
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d. Thought processes
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e. Cognition

Rationale: A mental status examination assesses various aspects of a client’s mental functioning, including appearance, mood and affect, thought processes, and cognition. Past medical history is part of the overall health assessment but not specific to the mental status examination.

Question 27

A client who is experiencing mania is talking rapidly and pacing around the unit. Which nursing intervention is most appropriate?
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a. Speaking to the client in a calm, low voice and redirecting them to a quieter activity.
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b. Ignoring the client’s behavior to avoid escalating the situation.
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c. Joining in the client’s excited conversation and matching their energy level.
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d. Placing the client in seclusion to prevent them from disturbing others.

Answer 27

a. Speaking to the client in a calm, low voice and redirecting them to a quieter activity.

Rationale: Clients experiencing mania can be easily overstimulated. Speaking in a calm, low voice and redirecting them to a quieter activity can help reduce their agitation and promote self-control.

Question 28

28. A client is admitted to a psychiatric unit for involuntary treatment after threatening to harm their family. The client is angry and states, “You can’t keep me here! I have rights!” Which nursing response is most appropriate?
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    a. “You are here because you are sick and need help.”
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    b. “You don’t have any rights because you were brought here involuntarily.”
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    c. “I understand that you are upset. Let’s talk about your rights as a patient.”
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    d. “If you don’t calm down, we will have to restrain you.”

Answer 28

c. “I understand that you are upset. Let’s talk about your rights as a patient.”

Rationale: Clients admitted involuntarily still retain certain rights. Acknowledging the client’s anger and offering to discuss their rights demonstrates respect and can help de-escalate the situation.

Question 29

A client with borderline personality disorder is exhibiting manipulative behavior, splitting staff members against each other, and making frequent threats of self-harm. Which nursing intervention is most important?
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a. Giving in to the client’s demands to prevent self-harm.
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b. Maintaining consistent limits and boundaries with the client.
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c. Ignoring the client’s manipulative behavior.
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d. Isolating the client to prevent them from influencing others.

Answer 29

b. Maintaining consistent limits and boundaries with the client.

Rationale: Clients with borderline personality disorder often test boundaries and attempt to manipulate others. Consistent limits and boundaries are crucial for managing their behavior and promoting therapeutic growth.

Question 30

The nurse is documenting in a client’s medical record. Which of the following entries is an example of accurate and objective documentation?
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a. “Client is making good progress in therapy.”
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b. “Client appears to be depressed today.”
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c. “Client is uncooperative and refuses to participate in activities.”
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d. “Client observed pacing back and forth in the hallway, talking rapidly, and gesturing wildly.”

Answer 30

d. “Client observed pacing back and forth in the hallway, talking rapidly, and gesturing wildly.”

Rationale: Documentation should be factual and avoid subjective interpretations. Option D provides a clear and objective description of the client’s observed behavior