Mental Health and Psychiatric Nursing NCLEX
A client with schizophrenia says to the nurse, “The world turns as the world turns on a ball at the
beach. But all the world’s a stagecoach and I took the bus home.” The nurse recognizes this
statement as an example of which of the following?
1. Concrete thinking
2. Loose associations
4. Word salad
The nurse is caring for a new mother whose infant has been diagnosed with Down
syndrome. The client says to the nurse, “I’m so worried. My husband is so devastated that he
won’t even look at the baby.” What is the best response by the nurse?
1. “Both of you will benefit from supportive counseling.”
2. “How are you feeling about your baby?”
3. “I will have the doctor speak to your husband.”
4. “Why do you think your husband feels this way?”
A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which
combination of medications does the nurse question?
1. A client with anxiety prescribed escitalopram and alprazolam
2. A client with bipolar disorder prescribed risperidone and lithium
3. A client with depression prescribed escitalopram and selegiline
4. A client with depression prescribed sertraline and zolpidem
A 3-month-old client has stopped breathing. Identify the area where the nurse should check the
The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg,
pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized
albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that
indicates the drug is producing the therapeutic effect?
1. Constricted pupils
2. Heart rate of 120/min
3. Respirations of 24/min
A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for
contracting a nosocomial infection?
1. 51-year-old client who received a permanent pacemaker 48 hours ago
2. 60-year-old client who had a myocardial infarction 24 hours ago
3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
4. 75-year-old client with dementia and dehydration who is on IV fluids
A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer’s
solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution
and IV tubing. Arrange the actions in the order that they should be performed. All options must
1. Uncap the distal end of the tubing.
2. Close the roller clamp on the IV tubing.
3. Open the roller clamp and fill the tubing.
4. Attach the distal end of the tubing to the client.
5. Spike the IV bag and half-fill the drip chamber.
A unit of packed red blood cells has been prescribed for a client with low hemoglobin and
hematocrit typing and cross matching. The nurse receives a telephone call from the blood bank
and is informed that the unit of blood is ready for administration. In order of priority, how should
the nurse plan the actions to take? Arrange the actions in the order that they should be performed.
All options must be used.
1. Hang the bag of blood.
2. Obtain the unit of blood from the blood bank.
3. Ensure that an informed consent has been signed.
4. Insert an 18- or 19-gauge intravenous catheter into the client.
5. Verify the health care provider’s (HCP’s) prescription for the blood transfusion.
6. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and
verifying client identity.
The nurse is performing an assessment of a newborn admitted to the nursery after birth. On
assessment of the newborn’s head, what should the nurse anticipate to be the most likely findings
related to the fontanels? Select all that apply.
1. A bulging anterior fontanel
2. A depressed anterior fontanel
3. A soft and flat anterior fontanel
4. A triangular-shaped anterior fontanel
5. A triangular-shaped posterior fontanel
6. Size of posterior fontanel is 4 cm by 6 cm
The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which
findings indicate the presence of a side effect associated with this medication? Select all that
2. Weight loss
5. Mild heat intolerance