1. What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?

  • Assist the client to relate to others.
  • Make the hospital atmosphere more home-like.
  • Help the client become accepted in a controlled setting.
  • Maintain the highest level of safe, independent functioning.

2. How should a nurse intervene when a regressed, emotionally disturbed client voids on the floor in the sitting room of the mental health unit?

  • Make the client mop the floor.
  • Restrict the client’s fluids for the rest of the day.
  • Toilet the client more frequently with supervision.
  • Withhold the client’s privileges each time the client voids on the floor.

3. While watching TV in the day room, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs out of the room to the far end of the hallway. What is the most therapeutic action by the nurse?

  • Walk to the end of the hallway where the client is standing.
  • Accept the action as being the impulsive behavior of a sick person.
  • Ask another client in the day room why the client acted as she did.
  • Document the incident in the client’s record while the memory is fresh.

4. A client’s severe anxiety and panic are often considered to be “contagious.” What action should be taken when a nurse’s personal feelings of anxiety are increasing?

  • Refocus the conversation on some pleasant topics.
  • Say to the client, “Calm down. You are making me anxious, too.”
  • Say, “Another staff member is coming in. I will leave and return later.”
  • Remain quiet so that personal feelings of anxiety do not become apparent to the client.

5. A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate what the client perceived at the change of shift report?

  • A delusion
  • An illusion
  • A hallucination
  • An idea of reference

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 1. After 4 days on the inpatient psychiatric unit, a client on suicidal precautions tells the nurse, “Hey, look! I was feeling pretty depressed for a while, but I’m certainly not going to kill myself.” What is the nurse’s best response to this statement?

  • “You do seem to be feeling better.”
  • “We should talk some more about this.”
  • “We have to observe you until you are better.”
  • “I don’t understand what you mean by killing yourself.”

2. What should a nurse include in the initial plan of care for a client with the long-standing, obsessive-compulsive behavior of hand washing?

  • Determine the purpose of the ritualistic behavior.
  • Limit the time allowed for the ritualistic behavior.
  • Suggest a symptom substitution technique to refocus the ritualistic behavior.
  • Develop a routine schedule of activities to reduce the need for the ritualistic behavior.

3. What should a nurse consider when planning care for a client who is using ritualistic behavior?

  • Nurses must attempt to limit the ritualistic behavior.
  • Clients need to realize that ritualistic behavior serves no purpose.
  • Nurses should try to divert the ritual immediately after it is started.
  • Clients do not want to repeat the ritual but feel compelled to do so.

4. A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?

  • “How have you managed your problems in the past?”
  • “What do you feel you have learned from this suicide attempt?”
  • “How will you manage the next time your problems start piling up?”
  • “Were there other things going on in your life that made you want to die?”

5. A client with a diagnosis of major depression refuses to participate in unit activities because of being “just too tired.” What is the nurse’s best approach?

  • Plan one rest period during each activity.
  • Explain why the staff believes the activities are therapeutic.
  • Encourage the client to express negative feelings about the activities.
  • Accept the client’s feelings about activities calmly, while setting firm limits.

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 1. What is essential for the nurse to do when approaching a client during a period of overactivity?

  • Use a firm but caring and consistent approach.
  • Anticipate and physically control the hyperactivity.
  • Allow the client to choose the activities in which to participate.
  • Let the client know the staff will not tolerate destructive behavior.

2. During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, “Welcome to the funny farm. I’m Jo-Jo, the head yo-yo.” Which meaning can the nurse assign to the client’s statement?

  • Trying to fill the “life-of-the-party” role
  • Looking for attention from the new staff
  • Unable to distinguish fantasy from reality
  • Anxious over the arrival of new staff members

3. A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discuss­ing this therapy with the client?

  • Sleep will be induced and treatment will not cause pain.
  • Treatment is totally safe with the new methods of administration.
  • You can ask any question you like, but it is better not to talk about it.
  • There may be some unrecoverable short-term and long­term memory loss.

4. A nurse is assisting with the administration of electrocon­vulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate?

  • Loss of appetite
  • Postural hypotension
  • Complete temporary loss of memory
  • Confusion immediately after the treatment

Read more: Psychiatric Nursing - Free NCLEX Test 2024

 1. A 35-year-old client is scheduled for a conization of the cervix to remove dysplastic cervical cells and to determine the extent of involvement. What behavior indicates to a nurse that the client understands the postoperative instructions?

  • States she will not resume sexual intercourse for 48 hours
  • Verbalizes expectations of a vaginal discharge for 3 to 5 days
  • Demonstrates the ability to change sterile surgical dressings
  • Affirms that because she has children she does not mind being sterile

2. A nurse is teaching clients to determine the time of ovulation by taking the basal temperature. What change is expected to occur in the basal temperature during ovulation?

  • Slight drop and then rises
  • Sudden rise and then drops
  • Marked rise and remains high
  • Marked drop and remains lower

3. The school nurse is discussing issues concerning premarital sex with a group of adolescents taking a health education course. The students are asked to write an essay on what they have learned about preventing pregnancy. Which comment alerts the nurse to have a private discussion with the student?

  • “I can’t get pregnant if I have sex during my period.”
  • “The pill may prevent me from getting pregnant, but I can still get an STI.”
  • “I won’t get pregnant if I swim in a pool where a boy has just masturbated.”
  • “A condom will not always protect me from getting pregnant, but it can protect me from getting an STI.”

4. A 15-year-old adolescent tells a school nurse, “I have persistent pain during my periods.” What should the nurse encourage her to do?

  • Continue daily activities.
  • Have a gynecologic examination.
  • Eat a nutritious diet containing iron.
  • Practice relaxation of abdominal muscles.

5. A nurse teaches women in the fertility clinic that after ovulation has occurred, the ovum is thought to remain viable for:

  • 1 to 6 hours.
  • 12 to 18hours.
  • 24 to 36hours.
  • 48 to 72hours.

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 1. A pregnant client uses a computer continuously during her working hours. This has implications for her plan of care during pregnancy. What should a nurse recommend?

  • “Try to walk around every few hours during the workday.”
  • “Ask for time in the morning and afternoon to elevate your legs.”
  • “Tell your boss that you cannot work beyond the second trimester.”
  • “Ask for time in the morning and afternoon to get something to eat.”

2. During a physical in the prenatal clinic the client’s vaginal mucosa is observed to have a purplish discoloration. What sign should the nurse document in the client’s clinical record?

  • Hegar
  • Goodell
  • Chadwick
  • Braxton Hicks

3. A client tells the nurse that the first day of her last menstrual period was July 22, 2010. What is the estimated date of birth?

  • May 7, 2011
  • April 29 2011
  • April 22, 2011
  • March 6, 2011

4. When involved in prenatal teaching, a nurse should inform clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase?

  • Metabolic rate
  • Production of estrogen
  • Secretion from the Bartholin glands
  • Supply of sodium chloride to the vaginal cell

5. What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?

  • Labor and birth
  • Signs and symptoms of complications
  • Role transition into parenthood and its acceptance
  • Physical and emotional changes resulting from pregnancy

Read more: NCLEX Practice Tests 2024

 1. How should a nurse direct care for a client in the transition phase of the first stage of labor?

  • Decrease IV fluid intake.
  • Help the client to maintain control.
  • Reduce the client’s discomfort with medications.
  • Institute simple breathing patterns during contractions.

2. A client is admitted to the birthing unit in active labor. What should the nurse expect after an amniotomy is performed?

  • Diminished bloody show
  • Increased and more variable FHR
  • Less discomfort with contractions
  • Progressive dilation and effacement

3. During labor a client who has been receiving epidural anes­thesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse’s immediate reaction?

  • Turn the client on her side.
  • Notify the health care provider.
  • Check the vaginal area for bleeding
  • Monitor the fetal heart rate every three minutes

4. At 9 PM visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?

  • Remind the client’s sister that visiting hours are over.
  • Get written permission from the client for her sister to remain.
  • Call the evening nursing supervisor to tactfully handle the situation.
  • Encourage the sister to participate in care as much as the client wishes.

5. A nurse assesses the frequency of a client’s contractions by timing them from the beginning of a contraction:

  • until the uterus starts to relax.
  • to the end of a second contraction.
  • until the uterus completely relaxes.
  • to the beginning of the next contraction.

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