NR-326 Mental Health Nursing - Set 5 - Part 2

Correct Answer: "Your pain is real, and I want to hear what it is like."

Naming the pain as real and inviting the client to describe her experience validates suffering without arguing about causation. That acknowledgment keeps the relationship open, which is what allows later work on coping. Option a is incorrect because normal results offer only brief relief before the checking and worry return stronger. Repeating reassurance is the reflex wrong move here and it feeds the cycle the nurse is trying to interrupt. Option b is incorrect because a why question asks for an explanation the client cannot supply and pushes her to defend herself. It also invites more talk about the previous physician instead of her present distress. Option d is incorrect because steering away from the topic reads as dismissal, the very thing that drove this client from her last provider. Redirection belongs after acknowledgment, not in place of it.

Correct Answer: "I have noticed the migraine starts just before group each morning."

Stating the observed pattern and then stopping hands the connection to the client without accusing her. The nurse can medicate ahead of the session and still hold the expectation that she attends. Option a is incorrect because it converts a neutral observation into a motive the client never stated. Interpretation of this kind sounds like an accusation of faking, and the symptom is not consciously produced. Option b is incorrect because excusing attendance rewards the headache with escape from the very thing that triggers it. Avoidance grows each time it works, so the expectation of group should hold. Option c is incorrect because citing clear imaging tells the client her pain is imaginary. Dismissal ends the working relationship, and the pain hurts regardless of what the scan shows about tissue.

Correct Answer: Visit briefly at set times regardless of symptoms

Scheduled contact separates attention from symptom reporting, so the client no longer has to hurt in order to be visited. This is the most tested intervention in somatic symptom disorder care. Option a is incorrect because symptom contingent attention teaches the client that complaints bring the nurse. Reinforcing the very behaviour that maintains the disorder makes the reports more frequent rather than fewer over the admission. Option c is incorrect because announcing a blanket refusal to examine anything is unsafe. A person with this disorder can still develop appendicitis, so each new or changed complaint deserves vital signs and a focused assessment. Option d is incorrect because opioids and benzodiazepines are specifically avoided in this population. Chronic pain complaints plus high anxiety make substance dependence a named complication, and stronger analgesia does not touch the underlying distress.

Correct Answer: Placing a hand on the client's shoulder

Touch is easily misread as restraint by an aroused client and can trigger the assault it was meant to prevent. The charge nurse stops that hand before it lands on his shoulder. Option a is incorrect because an angled stance with visible open hands is exactly right. Squaring off reads as confrontation and hidden hands read as concealment, so this posture lowers threat rather than adding to it. Option b is incorrect because short simple phrases delivered slowly match what an aroused brain can actually process. Long explanations overload it, and people unconsciously mirror the pace they hear, so the slow voice pulls him down. Option d is incorrect because clearing the corridor removes the audience, and an escalating person with peers watching cannot back down without losing face. Fewer bystanders also means fewer people to protect if things go badly.

Correct Answer: The client meets criteria for delirium

The screening algorithm needs acute onset with fluctuation plus inattention, then either disorganised thinking or altered arousal. Yesterday's sharp baseline, the failed months task, rambling speech, and drowsiness satisfy every required element. Option b is incorrect because a chronic process cannot appear overnight, and dementia leaves arousal clear. Drowsiness combined with a baseline described as sharp only yesterday rules out an isolated long standing cognitive decline. Option c is incorrect because tiredness alone does not scatter speech across unrelated topics or erase orientation to place. Poor sleep can worsen an episode, yet calling this fatigue would leave an underlying physical illness unfound. Option d is incorrect because depressed clients keep orientation and arousal intact while complaining about memory and answering that they do not know. Nothing in this picture describes sadness, hopelessness, or a recent loss.

Correct Answer: Offering fluids and assisting with toileting

Hydration, toileting, and comfort measures fall within the assistive role under the nurse's supervision. Judgement calls, including assessment of skin and circulation and the decision to release, stay with the registered nurse. Option a is incorrect because judging readiness for release requires interpreting behaviour against criteria such as following direction and contracting for safety. That evaluation is nursing judgement and cannot be handed to an unlicensed worker. Option b is incorrect because neurovascular checks distal to each device detect compromised circulation before tissue is damaged. Assistive personnel may report what they notice, but the assessment itself belongs to the nurse. Option c is incorrect because limbs come off one at a time only when the nurse has confirmed the client is safe. Timing that sequence carries real risk and sits outside any delegated scope.

Correct Answer: "I will put a lock on the bathroom door."

Locks on bedroom and bathroom doors trap a confused person inside and delay help. Home teaching calls for removing those locks, so this plan needs correction before an emergency finds the door fastened. Option b is incorrect because turning the water heater down guards against scald injury when judgment about temperature fails. That change belongs on every dementia home checklist, so the wife has understood this point correctly. Option c is incorrect because clearing loose rugs removes a leading tripping hazard for someone with gait changes and poor visuospatial judgment. Fall prevention at home starts exactly here, making the statement accurate rather than mistaken. Option d is incorrect because an identification bracelet helps return a wandering client safely when he cannot say his own address. Wandering precautions include this alongside door alarms and a current photograph, so no correction is required.

Correct Answer: The triggering phase

Restlessness, pacing, voice changes, and muscle tension shortly after a precipitating event mark the triggering phase. Recognising it matters because a calm approach and attention to the unmet need still work here. Option a is incorrect because escalation brings threatening speech, profanity, and refusal of redirection as the client loses the ability to be reasoned with. This client still walks and talks without directing anything at staff. Option c is incorrect because the crisis phase means control is already lost, with physical aggression toward people or property under way. Words no longer reach the client then, and a trained team response is required. Option d is incorrect because recovery follows an incident, when tension is falling and the client grows quieter and able to talk. Everything described here is building rather than settling, so the sequence runs the other way.

Correct Answer: Depression presenting as pseudodementia

Recent bereavement, prominent complaints about memory, I do not know answers, and intact orientation point to depression mimicking dementia. Cognition improves once the mood disorder is treated, so screening for depression and suicide risk comes first. Option a is incorrect because clients with Alzheimer disease hide their deficits, filling blanks with invented detail and insisting nothing is wrong. Here the client volunteers the complaint himself while family worry has not even been mentioned. Option b is incorrect because a delirious client cannot hold attention or stay oriented, and the presentation would shift within a single day. Three months of steady low mood after a loss does not match that acute picture. Option c is incorrect because frontal and temporal degeneration announces itself through personality change, disinhibition, or effortful speech, usually starting between ages forty five and sixty five. Memory holds up early, and grief plays no part in it.

Correct Answer: Proceed with only the parts she accepts

Consent is taken separately for each step, and she may decline any part or stop at any point. Honouring the refusal returns control to someone whose control was taken, which is the therapeutic principle. Option a is incorrect because the kit is not an all or nothing package. Telling her otherwise is untrue, and it pressures a woman who has just had every choice taken from her. Option b is incorrect because persuading her serves the case rather than the survivor. Her recovery is shaped by how this first response treats her, and lobbying for evidence undercuts that. Option d is incorrect because delaying collection risks losing findings that fade with time. She has already made a clear decision, so the examiner completes what she consented to and stores it.

Correct Answer: Assess for pain and a full bladder

Resistance during personal care is communication, so the nurse looks for the unmet need behind it. Pain on movement and a full bladder are the two most common drivers and are correctable before any other approach changes. Option b is incorrect because medication for staff convenience is chemical restraint, and sedatives raise fall risk and deepen confusion. Drug treatment follows only after behavioural approaches have genuinely been tried and have failed. Option c is incorrect because speed and extra hands feel threatening to someone who cannot follow what is happening. One caregiver moving slowly, explaining each step, produces far less distress than a rushed pair. Option d is incorrect because abandoning hygiene creates skin breakdown, odour, and infection while leaving the trigger unexamined. Charting a refusal records the problem without solving it, and the same struggle returns the next morning.

Correct Answer: A life transition crisis she planned herself

The move was planned and chosen, yet she has lost her footing inside it. A life transition crisis is exactly that, a deliberate change during which the person feels control slipping away. Option a is incorrect because adventitious events are disasters sweeping through whole populations, such as an earthquake or an act of terrorism. One student struggling on a new campus disturbs nobody else's equilibrium. Option b is incorrect because traumatic stress crises follow an unexpected external event the person had no power over, such as a violent crime or a serious collision. She chose this move and knew it was coming. Option d is incorrect because a psychiatric emergency means functioning has collapsed to the point that the person cannot take responsibility for their own behaviour or prevent injury. She is distressed but still attending and reporting accurately.

Correct Answer: Ensure the neurological evaluation is completed first

Sudden blindness, paralysis or seizure activity is not labelled conversion until organic causes are excluded. Missing a stroke because the symptom followed a stressful event is the harm this rule exists to prevent. Option a is incorrect because consent to transfer does nothing about the missing workup. A willing client with an undiagnosed cerebral event still needs imaging and a neurology assessment before any psychiatric admission is arranged. Option c is incorrect because promising a recovery nobody can guarantee is false reassurance. Most acute conversion presentations do settle within days to weeks, but saying so before a diagnosis exists is premature and unsafe. Option d is incorrect because detailed exploration of the precipitating event belongs to therapy, not to an undiagnosed client in the emergency department. Physical safety and a medical explanation come ahead of psychological work.

Correct Answer: An adventitious crisis of disaster proportions

Adventitious crises are unplanned events of disaster proportions that hit many people simultaneously, and a tornado levelling a school and neighbourhoods fits exactly. The response is aimed at a whole community rather than one client. Option a is incorrect because situational crises hit an individual or a family through events like illness, divorce, or job loss. Scale is what separates the two, and this storm took down an entire town. Option b is incorrect because maturational crises grow out of normal development, when someone stalls at a passage like leaving home or entering midlife. A tornado has no relationship to any developmental milestone. Option c is incorrect because life transition crises follow planned moves such as starting college, marrying, or relocating, where the person feels a loss of control over a chosen change. Nobody chose this storm.

Correct Answer: Review a detailed safety plan for the departure

The weeks around leaving carry the highest risk of serious injury and homicide, so the plan she needs is concrete: hidden bag, documents, a code word, and where she goes if he arrives. Option b is incorrect because announcing the departure hands him the one piece of information most likely to trigger an attack. Warning an abusive partner converts a planned exit into a confrontation. Option c is incorrect because approval is not protection. Praise leaves her walking into the most dangerous stretch of the relationship with nothing rehearsed, and it also implies the nurse would judge a different choice. Option d is incorrect because couples sessions are contraindicated where one partner uses violence for control. Speaking honestly in front of him is unsafe, and anything she says can be used against her later.

Correct Answer: She is showing hypoactive delirium

A withdrawn, drowsy older adult who has changed from her admission baseline is showing the quiet subtype, the most common form in this age group and the one missed most often. It carries the worst outcomes. Option a is incorrect because anesthetic effects clear well within a day, so lingering sedation on the second postoperative morning needs explaining rather than excusing. Attributing it to the surgery lets sepsis or hypoxia continue untreated. Option b is incorrect because low mood develops across weeks and leaves orientation and arousal intact. Nothing suggests sadness or loss here, and a depressed client stays awake and alert while complaining about how she feels. Option c is incorrect because settling into unfamiliar surroundings does not blunt speech or slow responses. Calling this adjustment repeats the error the assistive personnel made, and the quiet client then goes unassessed for a physical cause.

Correct Answer: Check oxygen saturation and blood glucose

New confusion demands a fast look for a correctable physiologic threat. Pulse oximetry and a point of care glucose take seconds, and hypoxia or hypoglycemia can be reversed immediately once either one is identified. Option a is incorrect because repeating the date supplies comfort without touching the cause. Orientation is supportive care in delirium, and a client whose brain is starved of oxygen will not hold the information anyway. Option c is incorrect because arranging a sitter addresses supervision hours from now, while the client needs assessment within the next minute. Staffing decisions follow the assessment findings rather than substituting for them. Option d is incorrect because waiting turns an acute change in condition into an unreported one. Delirium signals an underlying medical problem, so charting alone delays antibiotics, oxygen, or a medication review that the client urgently needs.

Correct Answer: Her partner answers every question for her

A partner who speaks for the client and will not allow her to answer alone is a classic control marker. It blocks private screening, which is why the nurse separates them before asking anything. Option a is incorrect because a partner sitting in the waiting room is doing what most companions do. Concern rises when he refuses to leave the room or speaks in her place, not when he waits. Option b is incorrect because an injury that fits the story told is reassuring rather than suspicious. The red flag runs the other way: bruising patterns that could not have come from the described fall. Option d is incorrect because a single documented visit says nothing on its own. Repeated presentations for vague complaints across different facilities would matter, and so would delay between the injury and the arrival.

Correct Answer: Start a scheduled toileting round at night

Many falls happen on the way to the toilet, so taking the client before urgency builds removes the reason for the unsafe trip. Night lights and a low bed support the same goal. Option a is incorrect because a vest increases agitation, injury, and immobility while the client struggles against it. Restraint is permitted only for imminent danger after gentler measures fail, and it never counts as fall prevention. Option b is incorrect because full rails turn a low fall into a climb over a barrier, and injuries worsen accordingly. Regulators treat four raised rails as a restraint rather than a safety device. Option c is incorrect because restricting fluids invites dehydration, concentrated urine, constipation, and infection, each of which can trigger acute confusion. The client still needs to void, so the nighttime trips continue anyway.

Correct Answer: Remote memory outlasts recent memory

Alzheimer pathology strikes the hippocampus first, so newly formed memories fail while long stored ones survive. That is why reminiscence about the distant past works well and why safety instructions given an hour ago will not stick. Option a is incorrect because it reverses the actual sequence. Recent events are the first casualties in this disease, which is exactly why the client remembers her wedding yet has lost the last hour entirely. Option b is incorrect because simultaneous collapse of both stores appears only at the end of the illness. This client still retrieves decades old detail fluently, which shows that her remote store remains richly available. Option d is incorrect because forgetting is the opening symptom rather than a late one. Alzheimer disease announces itself through misplaced objects, repeated questions, and lost appointments long before language, movement, or swallowing are affected.