Mental Health NSG 221

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Sample questions from Mental Health NSG 221

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 24-year-old client in an inpatient psychiatric unit says, "I have a plan to take all the pills in my apartment when I get home." The client is calm, denies taking anything today, and has stable vital signs. What should the nurse do first?

   • A.Ask the client to sign a no-suicide contract and continue routine checks
   • B.Initiate constant observation and immediately notify the psychiatric provider
   • C.Encourage the client to attend group therapy to discuss the feelings
   • D.Ask the client to promise to call a friend if suicidal thoughts return

   Rationale: A specific plan and access to means indicate imminent suicide risk, so constant observation and prompt team notification are priorities. A no-suicide contract and a promise to call someone do not ensure safety. Group therapy may help later but does not replace immediate protection.

2. 2.A 32-year-old client in the emergency department reports hearing a voice say, "You should cut yourself." The client is pacing, has a temperature of 37.0 C, pulse 96/min, and respirations 18/min. Which response is best?

   • A."The voice is not real, so you can ignore it."
   • B."What is the voice telling you to do, and do you feel you might act on it?"
   • C."Why do you think the voice is trying to hurt you?"
   • D."Try to distract yourself until the voice goes away."

   Rationale: The nurse should directly assess command hallucinations, including the specific command and the client's intent or ability to resist. Telling the client the voice is not real dismisses the experience, while asking why can sound blaming. Distraction may be useful after immediate safety risk is assessed.

3. 3.A 19-year-old client in an inpatient unit with anorexia nervosa has a BMI of 15.2, potassium of 3.0 mEq/L, and pulse 48/min. The client says, "I feel fine and do not need medical care." What is the nurse's priority action?

   • A.Offer a high-calorie snack and reassess the pulse in 4 hours
   • B.Place the client on cardiac monitoring and notify the provider
   • C.Discuss how body image affects the client's eating choices
   • D.Encourage the client to attend the next support group

   Rationale: Bradycardia and hypokalemia create a risk for dangerous dysrhythmias and require prompt medical assessment and monitoring. A snack alone does not address the immediate cardiac risk. Psychotherapy and support groups are important but are not the priority in an unstable client.

4. 4.A 76-year-old client on a medical unit becomes acutely confused and agitated overnight, has a temperature of 38.4 C, and is inattentive. The client was alert and oriented earlier that day. What should the nurse do first?

   • A.Request an antipsychotic medication for presumed dementia
   • B.Assess for an acute medical cause, including infection and hypoxia
   • C.Move the client to a psychiatric unit for further evaluation
   • D.Explain repeatedly that the client is in the hospital

   Answer and rationale are in the full material.

5. 5.A 29-year-old client in an outpatient clinic takes lithium for bipolar disorder and reports vomiting, worsening hand tremor, and unsteady walking. The lithium level is 1.8 mEq/L. What should the nurse do?

   • A.Give the next dose with food to reduce nausea
   • B.Hold lithium and notify the provider promptly
   • C.Encourage fluid restriction until the tremor improves
   • D.Reassure the client that tremor is an expected effect

   Answer and rationale are in the full material.