Mental Health Nursing NCLEX Questions 37-41

Increase your knowledge with this 5-item Mental Health Nursing NCLEX Questions.

 37. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

a) One-to-one suicide precautions
b) Suicide precautions with 30-minute checks
c) Checking the whereabouts of the client every 15 minutes
d) Asking the client to report suicidal thoughts immediately

38. Mental Health Nursing NCLEX Questions about the emergency department nurse who is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?

a) Information regarding shelters
b) Instructions regarding calling the police
c) Instructions regarding self-defense self-defense classes
d) Explaining the importance of leaving the violent situation

39. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday,” even though it has been a few months since the incident. What is the most appropriate nursing response?

a) “You need to try to be realistic. The rape did not just occur.”
b) “It will take some time to get over these feelings about your rape.”
c) “Tell me more about the incident that causes you to feel like the rape just occurred.”
d) “What do you think that you can do to alleviate some of your fears about being raped again?”

40. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

a) Requesting that a peer remain with the client at all times
b) Removing the client’s clothing and placing the client in a hospital gown
c) Assigning a staff member to the client who will remain with the client at all times
d) Admitting the client to a seclusion room where all potentially dangerous articles are removed

41. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply.

a) “I’m afraid of spiders.”
b) “I keep reliving the robbery.”
c) “I see his face everywhere I go.”
d) “I don’t want anything to eat now.”
e) “I might have died over a few dollars in my pocket.”
f) “I have to wash my hands over and over again many times.”






Mental Health Nursing NCLEX Questions
Answers and Rationale

37) A
- Rationale: One-to-one suicide precautions are required for a client who has attempted suicide. Options B and C may be appropriate, but not at the present time, considering the situation. Option D also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.

- Test-Taking Strategy: Focus on the strategic word priority, noting the words attempted suicide. The correct option is the only one that provides a safe environment.

38) A
- Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.

- Mental Health Nursing NCLEX Questions Test-Taking Strategy: Note the strategic word priority. Focus on the subject of the question, which relates to providing the client with a safe environment. The correct option provides a specific plan for safety.

39) C
- Rationale: The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option A immediately blocks communication. Option B places the client’s feelings on hold. Option D places the problem-solving totally on the client.

- Test-Taking Strategy: Note the strategic words most appropriate. Also, focus on the subject, the most appropriate response to the client. Use therapeutic communication techniques. The correct option is the only one that addresses the client’s feelings. Always address the client’s feelings first.

40) C
- Mental Health Nursing NCLEX Questions Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client’s safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.

- Test-Taking Strategy: Note the strategic word best. Focus on the subject, care of the client at risk for suicide. Eliminate option D because seclusion should not be the initial intervention. Eliminate option A next because the responsibility to safeguard a client is not the peer’s responsibility. Eliminate option B because removing one’s clothing would not maximize all possible safety strategies.

41) B, C, E
- Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement. “I’m afraid of spiders,” is more relative to having a phobia. The statement “I have to wash my hands over and over again many times” describes ritual compulsive behaviors to decrease anxiety for someone with obsessive compulsive disorder. Stating “I don’t want anything to eat now” is vague and could relate to numerous conditions.

- Test-Taking Strategy: Focus on the subject, post traumatic stress disorder. There is no indication about a fear of spiders being part of the problem. There is no information in the question to support that the client has ritual behaviors. The client stating he doesn’t want anything to eat at the time is not relative to this client’s situation. Responses B, C, and E all indicate the client is experiencing post traumatic stress disorder from a recent home invasion and robbery event.


After you reviewed your answers through its rationale, you can go to the next page to continue your review: 

Mental Health Nursing NCLEX Questions 42-45

Or go back to the first page:

Mental Health Nursing NCLEX Questions 32-36

Another set of Mental Health Nursing NCLEX Questions to sharpen your critical thinking skills and prepare you for the actual NCLEX exam.

 32. The nurse in the emergency department is caring for a young female victim of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?

a) Signs of depression
b) Normal reactions to a devastating event
c) Evidence that the client is a high suicide risk
d) Indicative of the need for hospital admission

33. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event?

a) Witnessing a murder
b) The death of a loved one
c) A fire that destroyed the client’s home
d) A recent rape episode experienced by the client

34. Mental Health Nursing NCLEX Questions about the nurse who is conducting an initial assessment on a client in crisis. When assessing the client’s perception of the precipitating event that led to the crisis, what is the most appropriate question?

a) “With whom do you live?”
b) “Who is available to help you?”
c) “What leads you to seek help now?”
d) “What do you usually do to feel better?”

35. The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?

a) A crisis state indicates that the client has a mental illness.
b) A crisis state indicates that the client has an emotional illness.
c) Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
d) A client’s response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

36. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?

a) “You need to stop that behavior now.”
b) “You will need to be placed in seclusion.”
c) “You seem restless; tell me what is happening.”
d) “You will need to be restrained if you do not change your behavior.”






Mental Health Nursing NCLEX Questions
Answers and Rationale

32) B
- Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options A, C, and D are incorrect interpretations.

- Test-Taking Strategy: Note the subject, client response to a crisis. Use knowledge regarding client responses to devastating events and focus on the symptoms noted in the question to direct you to the correct option.

33) B
- Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options A, C, and D identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental.

- Mental Health Nursing NCLEX Questions Test-Taking Strategy: Note the subject, situational crisis. Recall that this type of crises arises from an external source, is often unanticipated, and is associated with a life event that upsets an individual’s or group’s psychological equilibrium. This will direct you to the correct option.

34) C
- Rationale: The nurse’s initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options A and B assess situational supports. Option D assesses personal coping skills.

- Test-Taking Strategy: Note the strategic words most appropriate. Also note the subject, assessment techniques for the client in crisis, and note the words precipitating event and led to the crisis. Eliminate options A and B because these data would determine support systems. Eliminate option D because this question would be asked when determining coping skills.

35) D
- Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

- Test-Taking Strategy: Eliminate option C because of the closed-ended word all. Next, eliminate options A and B because a crisis does not indicate “illness.”

36) C
- Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option A is demanding behavior that could cause increased agitation in the client. Options B and D are threats to the client and are inappropriate.

- Test-Taking Strategy: Note the strategic words most appropriate. Eliminate option A because of the demand that it places on the client. Eliminate options B and D because they indicate threats to the client.


After you reviewed your answers through its rationale, you can go to the next page to continue your review: 

Mental Health Nursing NCLEX Questions 37-41

Or go back to the first page: