mental health nclex questions

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A male patient in the psychiatric unit experiencing a state of mania is walking the halls completely naked. How should the nurse respond initially? (select all that apply) Quietly escort the patient to his room.Tell the patient he will be secluded if he does not get dressed.Ask the other patients to go to their rooms.Confront the patient and insist he get dressed.Encourage the patient to get dressed.Withhold family visits due to inappropriate behavior.Quietly escort the patient to his room.Encourage the patient to get dressed.Explanation • The nurse should take control of the situation without causing the patient more anxiety. Walk the patient to his room and encourage him to dress there.• A manic patient often lacks good judgement and has poor impulse control, but may respond well to non-threatening encouragement.• A manic patient is more receptive to non-threatening direction than confrontation, and walking with the patient to his room and encouraging him to get dressed so that he can do something else he enjoys will get better results than issuing an order.• Confronting the patient or threatening the patient with seclusion or restraint will often escalate the situation or lead to resistance.• Asking the other patients to return to their rooms is not appropriate.• Withholding visitation is not an appropriate response.

The home care nurse assesses an older adult client living with adult children. The client is thin and frail, with bruising on the upper arms and back. Which circumstances alert the nurse to an increased risk of abuse?Select all that apply.Lower socioeconomic status of the older adult client's family.The elderly client has a psychiatric diagnosis, such as dementia or depression.The abuse of alcohol by the older adult client and/or a family member in the home.Physical or cognitive impairment making the client dependent on others for activities of daily living.Frequent emergency room visits for falls or unexplained illnesses.The elderly client has a psychiatric diagnosis, such as dementia or depression.

• The presence of any psychiatric diagnosis increases risk of elder abuse.

The abuse of alcohol by the older adult client and/or a family member in the home.

• Alcohol abuse increases risk of elder abuse.

Physical or cognitive impairment making the client dependent on others for activities of daily living.

• Financial or physical dependence on others increases the risk of elder abuse, in part because of the strain this dependency puts on the family.

The vulnerable older adult may also feel unable to speak out against any mistreatment they receive, beacuase they have nowhere else to go.Explanation Elder neglect and abuse affects an estimated 2-10% of adults, but is known to be under-reported. Nurses are mandated to report known or suspected elder abuse to Adult Protective Services or to law enforcement. Signs of possible neglect or abuse include bruising, bilateral injuries, oversedation, weight loss, poor hygiene, depression, agitation, or withdrawal. Older adult clients are often unable or scared to report abuse.Abusers have various motivations including trying to get their "fair share," having a history of using physical means to solve problems, and other social, biomedical, relationship, and environmental characteristics.Although lack of support system is a risk factor for elder abuse, socioeconomic status alone does not correlate with an increased risk.Frequent ER visits do not increase risk of elder abuse, but could be the outcome of abuse.

When providing care for a client who reports to the emergency department immediately after a sexual assault, which nursing actions are appropriate?Select all that apply.Offer a support person or crisis advocate Provide appropriate care for injuries Make the client sign the exam consent form Contact law enforcement Determine whether the sexual activity was consensual Offer a support person or crisis advocate Provide appropriate care for injuries Contact law enforcement Explanation • The nurse should offer an advocate from a local crisis center to provide support, reassurance and resources. The nurse should let the client know that she or he has the right to have a friend or family member present •The nurse should also provide care for and document any injuries and notify local law enforcement.•Law enforcement should be immediately available in case the client chooses to file a report or to transport the evidence collection kit. Some states mandate reporting any sexual assault, while other states only mandate reporting sexual assault for children or elders.•In the emergency room, the nurse is responsible for collecting evidence as well.• A consent must be obtained from the client in order to perform a sexual assault exam. The client should not be forced or pressured to consent to the exam, and adult clients may decline to make a report to law enforcement.• After emotional support is provided, the nurse will assist with exam and collect specimens. The nurse should document all objective evidence, including the client's physical condition and statements.• As a victim of sexual assault, the patient may be in a state of shock or may have feelings of guilt or confusion about the situation. It is never appropriate to question the client about the assault or in any way imply that the client may have been at fault.