NCLEX Questions
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
1. Restating
2. Listening
3. Asking the client “Why?”
4. Maintaining neutral responses
5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval
Answer: 1, 2, 4, 5
Rationale:
Therapeutic communication techniques include: listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing.
Asking “Why” is often interpreted as being accusatory by the client and should also be avoided.
Providing advice or giving approval or disapproval are barriers to communication
A client with a diagnosis of depression who has attempted suicide says to the nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.” Which response by the nurse demonstrates therapeutic communication?
1. “You have everything to live for.”
2. “Why do you see yourself as a failure?”
3. “Feeling like this is all part of being depressed.”
4. “You’ve been feeling like a failure for a while?”
Correct answer: 4
Rationale:
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating.
The remaining options block communication because they minimize the client’s experience and do not facilitate exploration of the client’s expressed feelings.
progressive deterioration in intellectual functioning (memory, communication, problem solving), secondary to structural or functional changes of the brain
What is dementia
Role play with your group an example of an open ended question
The gradual deterioration of function over months to years
what is dementia
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations
Answer: 2
Rationale:
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
A. Providing a supportive environment
B. Controlling the client’s feelings of anger
C. Discussing the details of the attack
D. Administering a hypnotic for sleep
Answer A is correct.
Rationale:
Providing a caring attitude and supportive environment will make the client feel safe.
Answer B is incorrect because the client needs to feel free to express anger.
Answer C is incorrect because it will increase the client’s anxiety.
Answer D is incorrect because it is not the most important aspect of care for the client with PTSD
refers to a state of confusion occuring in the late afternoon and spanning into the night? disoriented, agitated, exacerbated by changes in environment
What is sun-downing syndrome
Role play an example of restating with your client as a group
repeating what the nurse believes is the main point said. beneficial for patients who are angry, trying to find the main trigger for the anger.
Can be cause by repeated TBI or head injuries.
What is dementia
A client says to the nurse, “The federal guards were sent to kill me.” Which is the best response by the nurse to the client’s concern?
1. “I don’t believe this is true.”
2. “The guards are not out to kill you.”
3. “Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”
Rationale: It is most therapeutic for the nurse to empathize with the client’s experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
An appropriate nursing intervention for the client with borderline personality disorder is:
A. Observing the client for signs of depression or suicidal thinking
B. Allowing the client to lead unit group sessions
C. Restricting the client's activity to the assigned unit of care throughout the hospitalization
D. Allowing the client to select a primary caregiver
Answer A is correct. Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect because the client’s activities do not have to be restricted to the unit after the level of depression has been determined.
sudden improvement in mood, giving away personal items, saving/hoarding meds, preoccupied with death/suicide, sleep disturbance, non lethal self destructive behaviors would indicate a patient is at risk for what?
What is suicide
Role play an example of summarizing with a patient
reviews main ideas from the conversation, helps separate relevant info, serves as a review and closing
The LOC is typically altered and usually fluctuates rapidly
What is delirium
A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?
1. Vomiting, heart rate 120, chest pain
2. Nausea, mild headache, bradycardia
3. Respirations 16, heart rate 62, diarrhea
4. Temp 101°F, tachycardia, respirations 20
Answer A is correct. Vomiting, a heart rate of 120, and chest pain are symptoms of drinking alcohol while taking Antabuse. Additional symptoms include severe headache, nausea, cardiac collapse, respiratory collapse, convulsions, and death. Answers B, C, and D contain incomplete or inaccurate clinical signs of the combination of alcohol and Antabuse
While interviewing a client who abuses alcohol, the nurse learns that the client has experienced “blackouts.” The wife asks what this means. What is the nurse’s best response at this time?
A. Your husband has experienced short-term memory amnesia.”
B. “Your husband has experienced the loss of remote memory.”
C. “Your husband has experienced a loss of consciousness.”
D. “Your husband has experienced a fainting spell"
Answer A is correct. The most appropriate response is to answer the request of the client’s spouse and define blackouts. Answers B, C, and D are not accurate definitions of blackouts, so they are incorrect.
a sudden and acute decline in cognition, usually temporary and reversible and develops over hours to days. quick change between mental states
What is delirium
Role play with your group an example of paraphrasing with your patient
stating what the patient said but in the nurses own words. used to verify what the nurse interpreted from the patient is correct
Personality change is rapid
What is delirium.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide stimulation in the environment.
5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
Answer:
1, 2, 3, 5
Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
A. Extreme weight loss
B. Presence of lanugo over body
C. Erosion of tooth enamel
D. Muscle wasting
Answer C is correct. Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with bulimia nervosa.
Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.
an irreversible form of dementia from nerve cell deterioration
What is Alzheimer's
Role play an example of focusing with your client as a group
Helps patient develop or expand an idea. Allows nurse to collect specific information. Directs conversation towards topics of importance.
What is hyperactive (with agitation and restlessness)
What is hypoactive (with apathy and quietness)
Mixed (having both hyper and hypo)
Unclassified (cannot fit into any other category)