Question

A nurse on an inpatient mental health unit is assessing a client.

Answer 1

Correct Answers:

Hallucinations.
Illogical thinking.
Delusions.

Rationale :

Hallucinations

🔹 Hallucinations are a positive symptom of schizophrenia, representing an excess or distortion of normal functioning.

🔹 They are sensory perceptions (auditory, visual, tactile) without an external stimulus.

🔹 In this case, the client hears the FBI warning him, which is a typical auditory hallucination.

Illogical thinking

🔹 Disorganized or illogical thinking is another positive symptom, caused by disorganized thought processes.

🔹 The client’s statement about being a high-ranking military officer in danger shows disorganized thought content and difficulty with reality testing.

Delusions

🔹 Delusions are fixed, false beliefs not based in reality, and they are hallmark positive symptoms.

🔹 The client’s belief that the FBI is warning him of danger and that he is a high-ranking officer is a

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Answer 2

Correct Highlights :

questions reason to live if not working
became teary when asked about plans for activities
reports sleeping most of the day
reports loss of appetite

Rationale :

"Questions reason to live if not working"

🔹 This statement indicates possible suicidal ideation, which is the highest priority based on Maslow’s hierarchy (safety needs) and NCLEX safety & risk-reduction principles.

🔹 Clients expressing feelings of hopelessness or lack of purpose following major life changes, such as retirement, are at increased risk for self-harm or suicide.

🔹 The nurse must perform an immediate suicide risk assessment, asking direct questions about thoughts, plan, and means of self-harm.

🔹 Timely intervention, including mental health referral or crisis intervention, is crucial to prevent potential self-injury or suicide attempts.

"Became teary when asked about plans for activities"

🔹 Emotional lability and tearfulness are clinical signs of depression, which can progress to major depressive disorder (MDD) if untreated.

🔹 This reaction suggests emotional distress and anhedonia, often associated with feelings of worthlessness or hopelessness, increasing suicide risk.

🔹 Emotional changes should never be dismissed as “normal sadness,” particularly in older adults with recent life stressors (retirement).

🔹 Early detection and treatment, such as cognitive-behavioral therapy or pharmacologic therapy (SSRIs), can prevent worsening of depressive symptoms.

"Reports sleeping most of the day"

🔹 Hypersomnia or changes in sleep pattern is a hallmark symptom of depression.

🔹 Excessive sleeping can worsen feelings of fatigue, social isolation, and low self-esteem, creating a cycle that increases suicide risk.

🔹 Assessment should include evaluating energy level, daily functioning, and mood changes, as well as screening for other depressive symptoms.

🔹 Addressing sleep disturbances through behavioral activation strategies or adjusting treatment can help improve overall mood stability.

"Reports loss of appetite"

🔹 Appetite changes, whether loss of appetite (anorexia) or overeating, are part of the diagnostic criteria for major depressive disorder.

🔹 Loss of appetite can contribute to nutritional deficiencies, weight loss, and physical weakness, further reducing the client’s energy and motivation.

🔹 In combination with other symptoms (hopelessness, hypersomnia), it signals a significant change in daily functioning, warranting further psychiatric evaluation.

🔹 The nurse should monitor weight trends and assess for possible dehydration or malnutrition, especially in older adults.

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Answer 3

Correct Answers

Blank 1 Correct Option: Moderate anxiety.
Blank 2 Correct Option: Encourage the client to engage in physical activity and Encourage the client to problem solve.
Blank 3 Correct Option: Heart rate and Ability to focus on the task at hand.

Rationale :

Moderate anxiety (Condition)

🔹 The client’s symptoms—irritability, restlessness, fidgeting, tapping foot, nail biting, and preoccupation—are classic signs of moderate anxiety.

🔹 Moderate anxiety increases heart rate and respiratory rate, affects concentration, and requires repeated questioning to gain responses.

🔹 Other listed conditions (OCD, hoarding disorder, or body dysmorphic disorder) involve compulsions or body image distortions, which are not described here.

Actions.

Encourage the client to engage in physical activity

🔹 Physical activity is an effective coping mechanism to help discharge excess energy caused by increased sympathetic stimulation during anxiety.

🔹 Activities such as walking or stretching can lower muscle tension and restlessness, promoting relaxation.

Encourage the client to problem solve

🔹 Moderate anxiety still allows the client to focus with some assistance; problem-solving techniques help the client regain a sense of control and direction.

🔹 The nurse should use a calm and supportive approach to help identify triggers and develop healthy coping strategies.

Parameters to Monitor.

Heart rate

🔹 Tachycardia is a physiological response to anxiety caused by increased sympathetic nervous system activity.

🔹 Monitoring heart rate provides an objective measure of anxiety reduction as interventions are applied.

Ability to focus on the task at hand .

🔹 Moderate anxiety impairs concentration; improvement in the client’s ability to maintain focus indicates decreasing anxiety levels.

🔹 The nurse can assess this by observing whether the client answers questions promptly and engages in goal-directed behavior.

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Answer 4

Correct Answers

Blank 1 Correct Option: hypertensive crisis
Blank 2 Correct Option: ingestion of tyramine

Rationale :

⏺️ Selegiline is a monoamine oxidase inhibitor (MAOI) antidepressant. MAOIs inhibit the breakdown of tyramine, a naturally occurring amino acid found in certain foods.

⏺️ Ingesting tyramine-rich foods (e.g., aged cheeses, smoked meats like the requested smoked turkey, red wine, fermented products) can precipitate a hypertensive crisis because tyramine increases norepinephrine release, causing severe vasoconstriction and hypertension.

⏺️ Symptoms of hypertensive crisis include sudden severe headache, chest pain, tachycardia, and possible intracranial hemorrhage.

⏺️The nurse must provide clear dietary education, emphasizing strict avoidance of tyramine-containing foods and prompt reporting of headache or palpitations.

⏺️ Other listed conditions (tardive dyskinesia, rhabdomyolysis, infection) are not associated with selegiline or MAOIs.

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Answer 5

Correct Answers:

Install sensor devices on outside doors.
Position the mattress on the floor.
Put locks at top of doors.

Rationale :

Install sensor devices on outside doors

🔹 Wandering is a common behavior in Alzheimer’s disease; sensor devices provide early alerts to caregivers when the client attempts to leave the house.

🔹 This measure enhances safety and supervision, reducing the risk of falls or getting lost.

🔹 Caregivers should be educated on ensuring quick access to the client once alarms are triggered.

Position the mattress on the floor

🔹 Placing the mattress directly on the floor lowers the risk of serious injury if the client falls while getting in or out of bed.

🔹 This intervention is particularly important for clients with a history of falls or nocturnal wandering.

🔹 It is a non-restrictive safety intervention, aligning with best practices in fall prevention for cognitively impaired patients.

Put locks at top of doors

🔹 Placing locks at the top of doors (out of the client’s line of sight) helps prevent elopement since Alzheimer’s clients often fail to look up for locks.

🔹 This is a non-invasive safety measure that helps prevent wandering outside, which could lead to accidents or exposure to harsh environments.

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Answer 6

Correct Answers:

“I can quit drinking at any time. I don't need anyone's help."

Rationale :

♦️ Denial is a common defense mechanism in clients with alcohol use disorder (AUD), characterized by minimizing or rejecting the severity of the problem.

♦️ The statement “I can quit drinking at any time. I don't need anyone's help.” reflects denial because the client underestimates the loss of control over alcohol use and refuses to acknowledge the need for treatment or support.

♦️ Denial serves as a psychological defense to avoid confronting feelings of guilt, shame, or fear related to addiction.

♦️ The nurse should respond with therapeutic communication, such as using motivational interviewing techniques, to help the client explore the discrepancy between their words and their actual behavior.

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Answer 7

Correct Answers:

Lorazepam.

Rationale :

⏺️ Lorazepam, a benzodiazepine, is the first-line medication for managing alcohol withdrawal syndrome (AWS).

⏺️ It works by enhancing GABA activity, which helps reduce central nervous system hyperexcitability caused by alcohol cessation.

⏺️ Visible tremors, elevated BP, and tachycardia are hallmark early signs of alcohol withdrawal, and untreated, they can progress to seizures or delirium tremens (DTs).

⏺️ Lorazepam provides sedation, seizure prevention, and autonomic stabilization, making it the drug of choice in acute withdrawal management.

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Answer 8

Correct Answers:

Offer the client a PRN medication to red& their anxiety.

Rationale :

🟠 PRN antianxiety or antipsychotic medications are appropriate interventions when early signs of agitation or aggression appear, as they help reduce anxiety and prevent escalation.

🟠 Medications such as lorazepam (benzodiazepine) or haloperidol (antipsychotic) can stabilize mood and decrease hyperarousal, which may lead to aggression if untreated.

🟠 Early pharmacologic intervention is part of least restrictive measures, aiming to avoid the need for physical restraints or seclusion.

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Answer 9

Correct Answers:

A client did not receive their antipsychotic medication yesterday.

Rationale :

🔴Failure to administer an antipsychotic medication is classified as a medication error, which must always be documented through an incident report in a mental health facility.

🔴 Antipsychotic medications are essential in managing psychosis, mania, or schizophrenia, and missing a scheduled dose increases the risk of symptom relapse, behavioral agitation, or potential harm to self or others.

🔴 The incident report serves as a tool for quality improvement, identifying systemic issues or workflow problems that contributed to the missed dose.

🔴 Documentation in an incident report ensures accountability, helps track medication administration trends, and guides interventions to prevent future occurrences.

🔴 The report is non-punitive and is not part of the medical record; its purpose is to protect the client by improving patient safety protocols.

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Answer 10

Correct Answers:

Implement music therapy for the child.

Rationale :

🔹 Music therapy is an evidence-based intervention for children with autism spectrum disorder (ASD) as it helps stimulate communication, emotional expression, and social interaction in a non-threatening way.

🔹 Music can engage the child’s sensory processing in a soothing and structured manner, reducing anxiety and behavioral outbursts.

🔹 Children with ASD often respond well to structured, repetitive, and predictable activities, making music therapy an ideal approach for promoting emotional expression.

🔹 Unlike extended play sessions with other children, which may increase social stress, music therapy provides a safe, individualized environment to develop coping and self-regulation skills.

🔹 The nurse should collaborate with a certified music therapist to ensure that sessions are tailored to the child’s developmental level and sensory tolerance.

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QLexNursing

1 :
A nurse on an inpatient mental health unit is assessing a client.

Answer Options

2 :
A nurse in a primary care provider's office is caring for a client.

Correct Highlights :

3 :
A nurse is caring for a client who was recently admitted.

Correct Answers

4 :
A nurse is caring for a client on an acute care mental health unit.

Correct Answers

6 :
A nurse is assessing a client who has a new diagnosis of alcohol use disorder. Which of the following client statements should the nurse expect if the client is in denial about their diagnosis?

7 :
A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following medications should the nurse prepare to administer?

8 :
A nurse in a mental health facility is planning a training program for new staff members on managing aggressive clients. Which of the following instructions should the nurse plan to include?

9 :
A nurse is conducting chart audits for a mental health facility. Which of the following findings should the nurse identify as requiring completion of an incident report?

10 :
A nurse is caring for a school-age child who has autism spectrum disorder and has difficulty expressing emotions. Which of the following interventions should the nurse include in the child's plan of care?

QLexNursing

1 : A nurse on an inpatient mental health unit is assessing a client.

Answer Options

2 : A nurse in a primary care provider's office is caring for a client.

Correct Highlights :

3 : A nurse is caring for a client who was recently admitted.

Correct Answers

4 : A nurse is caring for a client on an acute care mental health unit.

Correct Answers

6 : A nurse is assessing a client who has a new diagnosis of alcohol use disorder. Which of the following client statements should the nurse expect if the client is in denial about their diagnosis?

7 : A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following medications should the nurse prepare to administer?

8 : A nurse in a mental health facility is planning a training program for new staff members on managing aggressive clients. Which of the following instructions should the nurse plan to include?

9 : A nurse is conducting chart audits for a mental health facility. Which of the following findings should the nurse identify as requiring completion of an incident report?

10 : A nurse is caring for a school-age child who has autism spectrum disorder and has difficulty expressing emotions. Which of the following interventions should the nurse include in the child's plan of care?

1 :
A nurse on an inpatient mental health unit is assessing a client.

2 :
A nurse in a primary care provider's office is caring for a client.

3 :
A nurse is caring for a client who was recently admitted.

4 :
A nurse is caring for a client on an acute care mental health unit.

6 :
A nurse is assessing a client who has a new diagnosis of alcohol use disorder. Which of the following client statements should the nurse expect if the client is in denial about their diagnosis?

7 :
A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following medications should the nurse prepare to administer?

8 :
A nurse in a mental health facility is planning a training program for new staff members on managing aggressive clients. Which of the following instructions should the nurse plan to include?

9 :
A nurse is conducting chart audits for a mental health facility. Which of the following findings should the nurse identify as requiring completion of an incident report?

10 :
A nurse is caring for a school-age child who has autism spectrum disorder and has difficulty expressing emotions. Which of the following interventions should the nurse include in the child's plan of care?