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NCLEX PN Mental Health
The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. Which of the following client statements demonstrate an improvement in coping? Select all that apply. A. "I plan dates involving outdoor activities, such as hiking, instead of going to dinner and a movie." B. "I sat in the pizza shop and drank a cola while watching people eat and then bought a slice to go." C. "I started having lunch with my coworkers even though I still become very anxious eating in public." D. "I went out of town on the day of the company picnic instead of making excuses for not eating." E. "I went to a coffee house with my boss and focused on an upcoming project while drinking a latte." Correct answer: B, C, and E. Social anxiety disorder (ie, social phobia) is characterized as intense anxiety or fear when exposed to a public or social situation (eg, public speaking, eating or drinking in front of others). Clients who have social anxiety disorder tend to avoid participating in social situations because of the heightened anxiety and insecurity they experience. Treatment of social phobias may include medication (eg, selective serotonin reuptake inhibitors, benzodiazepines) and psychotherapy (eg, cognitive-behavioral therapy, systematic desensitization) to assist in developing effective coping strategies. As part of systematic desensitization, the client is gradually exposed to the phobic trigger, which in turn decreases anxiety. Effective coping with social phobia is demonstrated by: · Experiencing increased comfort while engaging in phobic situations (eg, drinking a cola while watching people eat). · Developing insight and verbalizing feelings about the irrational fear.
· Distracting oneself by focusing on something other than the phobic situation (eg, preparing for a meeting while drinking a latte). Incorrect Answers [A. "I plan dates involving outdoor activities, such as hiking, instead of going to dinner and a movie."] Avoiding phobic situations (eg, planning activities unrelated to food, going out of town) reinforces maladaptive coping and prevents the client from working through the fear. [D. "I went out of town on the day of the company picnic instead of making excuses for not eating."] Avoiding phobic situations (eg, planning activities unrelated to food, going out of town) reinforces maladaptive coping and prevents the client from working through the fear. Educational objective:Social anxiety disorder (ie, social phobia) is characterized by intense anxiety or fear when exposed to a public or social situation. Effective coping is demonstrated by experiencing increased comfort when exposed to the phobia, developing insight and verbalizing feelings about the phobia, and distracting oneself during the phobic situation. Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? A. "I don't understand what you mean. Can you give me an example? B. "It is doubtful the president is out to get you." C. "Tell me more about the day your child died." D. "Why did you get so angry when she ignored you?" Correct Answer: D. "Why did you get so angry when she ignored you?" Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions.
Providing a realistic perspective of the rape may help clients develop a more objective view of their perceived role in the traumatic event and may reduce feelings of self-blame and guilt. The nurse needs to reinforce repeatedly that rape is never the victim's fault. Incorrect Answers: [A. "It may take time to overcome those thoughts and feelings."] This is a nontherapeutic response as it reinforces the client's feelings of self-blame and guilt. The best therapeutic response should reinforce that the client is not to blame for the rape. [B. "Those kinds of thoughts are self-destructive. You should stop thinking about it."] This is a nontherapeutic response; it does not assist in changing the client's perception of the traumatic event and implies that the client should not cope with the experience at all. [D. "You have to stop blaming yourself so you can move on with your life."] This is a nontherapeutic response. Clients cannot simply make negative feelings disappear; these need to be resolved through therapy. Educational objective:Clients who suffer from PTSD often experience feelings of guilt and shame; they believe that they are responsible for what happened and that, somehow, they could have prevented the traumatic event. Using therapeutic communication, the nurse needs to convey that what happened was not their fault. A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse? A. "How could your fiancé be wonderful after saying those things to you?" B. "I think you are better off without your fiancé." C. "Maybe the breakup was for the best." D. "Tell me how you felt when your fiancé broke up with you." Correct Answer: D. "Tell me how you felt when your fiancé broke up with you."
Clients with major depressive disorder experience feelings of worthlessness, low self-esteem, hopelessness, and guilt. Anger is turned inward and they may misinterpret reality and have an idealistic perception of a lost entity. They may blame themselves for what has happened, such as losing a loved one or being fired from a job. The nurse needs to remain nonjudgmental, listen to the client attentively, and convey a caring and accepting attitude to promote trust. Allowing the client to identify and verbalize feelings, including anger, in a comfortable environment will help the client see the situation in a more realistic way and come to terms with what has happened. Incorrect Answers: [A. "How could your fiancé be wonderful after saying those things to you?"] The nurse is challenging the client's perception of reality; this will increase the client's anxiety and inhibit further communication. [B. "I think you are better off without your fiancé."] The nurse is offering an opinion and challenging the client's statement; this is not a therapeutic response. [C. "Maybe the breakup was for the best."] The nurse is offering an opinion; it is not a therapeutic response. Educational objective:Nursing interventions for a depressed client who expresses feelings of worthlessness and guilt and has a distorted sense of reality include listening attentively, encouraging the client to verbalize feelings about what has happened, and helping the client view the situation in a more realistic way. The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client? Select all that apply. A. Allow the client to continue to exercise per usual routine B. Assist the client in reflecting on triggers of disordered eating C. Document the client's daily intake of calories and protein D. Remain with the client for the duration of each meal
[A. Allow the client to continue to exercise per usual routine] Clients admitted with anorexia nervosa should not continue to exercise, because this would cause further energy deficit and could worsen malnutrition and end-organ damage (eg, renal failure). Educational objective:Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should encourage discussion about dysfunctional eating triggers and allow the client to make food choices when possible. A nurse is monitoring several clients in the medical-surgical unit. The nurse identifies which client as being at greatest risk for the development of delirium? A. 32-year-old client with gastroenteritis B. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery C. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Correct Answer: D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Major predisposing factors for the development of delirium in hospitalized clients include:
- Advanced age
- Underlying neurodegenerative disease (stroke, dementia)
- Polypharmacy
- Coexisting medical conditions (eg, infection)
- Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia)
- Metabolic and electrolyte disturbances
- Impaired mobility - early ambulation prevents delirium
- Surgery (postoperative setting)
- Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. Incorrect Answers: [A. 32-year-old client with gastroenteritis] Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. [B. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery] Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. [C. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations] Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective:Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.
The nurse is conducting a seminar for parents of adolescents about health issues common to this age group. Which parent's statement indicates that the adolescent may have bulimia nervosa? A. "I found several empty boxes of laxatives in my child's wastebasket." B. "I have noticed my child has started wearing bulky, oversized clothing." C. "My child has lost 20 lb (9.1 kg) in the past 2 months." D. "My child has stopped going to the gym." Correct Answer: A. "I found several empty boxes of laxatives in my child's wastebasket." Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain. Compensatory behaviors may include laxative or diuretic use, self- induced vomiting, or excessive exercise 1-2 hours after binging. Other signs of BN may include: · Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of tooth enamel, dental caries) · Preoccupation with body image, weight, food, and dieting Incorrect Answers: [B. "I have noticed my child has started wearing bulky, oversized clothing."] Losing a significant amount of weight and hiding the weight loss (eg, wearing oversized, bulky clothing) are characteristics of clients with anorexia nervosa. [C. "My child has lost 20 lb (9.1 kg) in the past 2 months."] Losing a significant amount of weight and hiding the weight loss (eg, wearing oversized, bulky clothing) are characteristics of clients with anorexia nervosa.
[D. "My child has stopped going to the gym."] A client with BN would likely increase the amount of time spent exercising, not stop exercising. Educational objective:Bulimia nervosa is an eating disorder characterized by episodes of binge-eating followed by actions to prevent weight gain (eg, laxative overuse, self-induced vomiting, excessive exercise). The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse? A. "I know it must be terrible for you to see this, but your child will be fine." B. "Most people have permanent side effects after this type of episode." C. "Your child will have to remain here for observation until we know more." D. "Your child would be fine right now if not for taking these drugs." Correct Answer: C. "Your child will have to remain here for observation until we know more." In order to begin the appropriate treatment, it is important to distinguish clinically among the very similar presentations of intoxication, delirium secondary to a medical condition, dementia, and psychiatric disorders involving distorted perceptions of reality. Clients demonstrating altered mental status should be assessed for intoxication and medical causes of delirium (eg, electrolyte/glucose imbalances, pneumonia, sepsis, malnutrition) before consulting a mental health care professional. Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Clients may never experience another episode. Incorrect Answers: [A. "I know it must be terrible for you to see this, but your child will be fine."] The long-term prognosis after an episode of psychosis is impossible to predict with any accuracy. It is tempting to offer comfort to a client's family in a time of crisis, but this response offers false reassurance.
inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services). Incorrect Answers: [A. "Perhaps finding a caregiver to care for your spouse at night might be helpful."] Giving opinions and providing false reassurance are nontherapeutic, discourage nurse-client communication, and do not help identify CRS. [C. "Try not to worry. It's normal to feel overwhelmed when you are stressed."] Giving opinions and providing false reassurance are nontherapeutic, discourage nurse-client communication, and do not help identify CRS. [D. "You seem worried that you won't be able to provide the care that your spouse needs."] Restating client statements can be therapeutic because it shows that the nurse has analyzed what has been said. However, this response does not prompt the client to discuss potential difficulties in providing care. Educational objective:Caregiver role strain is a caregiver's perception of multifactorial difficulties associated with providing care to another person. The nurse should routinely monitor for signs of caregiver role strain (eg, fatigue, depression, isolation) because it can have a significant negative impact on a caregiver's health and well-being. A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the nurse preceptor before meeting with the client. Which of the following proposed nursing actions in the care plan requires intervention by the nurse preceptor? A. Assist the client in identifying the warning signs of a crisis B. Have the client write a list of people to contact for help and distraction C. Help the client develop ways of coping with suicidal thoughts D. Persuade the client to sign a contract promising not to commit suicide Correct Answer: D. Persuade the client to sign a contract promising not to commit suicide
No harm/no suicide contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. However, the practice is controversial; there is no evidence that such contracts reduce suicide, and they may provide a false sense of security. In addition, some clients may feel distrustful of a health care provider who asks a client to sign a suicide contract. If a contract is used, it should be short term with a specific stated time frame. At the end of the contract period, a new contract is negotiated. The student nurse must understand that the contract does not guarantee client safety and has no legal credibility. A more helpful strategy to support the client with suicidal ideation is safety planning. The plan is created in collaboration with the client and includes the following steps: · Creating a safe home environment - removal of firearms, sharp knives, razor blades, and unnecessary/unused medications · Identifying thoughts, situations, and behaviors that could trigger a suicidal crisis · Identifying ways to cope with suicidal thoughts, such as physical exercise or a distracting activity · Making a list of mental health agencies or hotlines that the client can go to or call when help is needed · Making a list of people who can be contacted for help or distraction Educational objective:Safety planning is a helpful strategy to support a client with suicidal ideation. The safety plan should include strategies for making the environment safe, how to identify and cope with signs of an impending crisis, and carrying a list of people, mental health agencies, and hotlines the client can contact for help. The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. A. Client breaks eye contact when discussing caregiver B. Client has lost 8 lb (3.63 kg) in the previous 4 weeks C. Client is wearing clothing that is out of style D. Client's eyeglasses have been visibly broken for 1 month E. Client's prescription medication is expired Correct Answers: A, B, D, and E
B. Notify neighbors of the client's tendency to wander C. Place a chain lock on the door above or below the client's eye level D. Place a safe return bracelet on the client's non-dominant hand Correct Answer: C. Place a chain lock on the door above or below the client's eye level Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: · Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads · Adding a motion sensor or alarm that goes off when someone tries to exit · Placing a large stop sign on door exits · Disguising a door with a curtain or wall hanging · Using childproof doorknob covers · Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. Incorrect Answers: [A. Ensure that the client is never left alone] Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. [B. Notify neighbors of the client's tendency to wander] Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. [D. Place a safe return bracelet on the client's non-dominant hand] Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective:The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level
on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms. A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse? A. "The gift shop is not even open right now." B. "I guess the day shift staff needs to be reminded of the rules." C. "What do you want to get from the gift shop?" D. "You do not have privileges for leaving the unit. I cannot give you a pass." Correct Answer: D. "You do not have privileges for leaving the unit. I cannot give you a pass." Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: · Setting limits that are realistic, nonpunitive, and enforceable · Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors
Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms:
- Reexperiencing the traumatic eventExamples include intrusive memories, flashbacks, recurring nightmares, feelings of intense distress/loss of control, and strong physical reactions to event reminders (eg, rapid heart rate, gastrointestinal distress, diaphoresis).
- Avoiding reminders of the traumaExamples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event.
- Increased anxiety and emotional arousalExamples include insomnia, irritability, outbursts of anger or rage, difficulty concentrating, hypervigilance, and exaggerated startle response. Incorrect Answer: [C. Feeling lethargic and apathetic] Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep. Educational objective:A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal. A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? A. Encourage the client to perform deep breathing exercises
B. Explore possible reasons for the episode C. Place the client in a private room and tell the client to relax D. Remain in the room with the client Correct Answer: D. Remain in the room with the client This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: · Maintaining a calm, matter-of-fact approach · Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures · Placing the client in a room with as few stimuli as possible · Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) · Having the client take slow, deep breaths if hyperventilation is a problem Incorrect Answers: [A. Encourage the client to perform deep breathing exercises] Deep breathing exercises can relieve hyperventilation, but the priority is to remain with the client to ensure safety. [B. Explore possible reasons for the episode] Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies.
