NCLEX Q and A with Rationales – PSYCHIATRIC NURSING
THERAPEUTIC COMMUNICATION TREATMENT MODALITIES:
1. After the 4th group meeting, the informal leader makes a statement that she
believes she can help the group more than the assigned facilitator and has better
credentials. Identify the group dynamics and stage of development.
– The informal leader is “testing,” which is a behavior indicative of a new group trying
to establish trust. This group is still in the orientation phase of development.
2. On an in-patient psychiatric unit, clients are expected to get up at a certain time,
attend breakfast at a certain time, and come for their medication at the correct
time. What form of therapy is incorporated into this unit? – Milieu.
3. The wife of a man killed in a motor vehicle accident has just arrived at the
emergency room and is told of her husband’s death. What nursing actions are
appropriate for dealing with this crisis?
– Take woman to a quiet room, ask her if there are family, friends, or clergy you can
call for her. Assess her need for medication and discuss with physician. Stay with
her, be firm and directive, and assess previous successful coping strategies.
4. A 10 yr. old is admitted to the children’s unit of the psychiatric facility after
stabbing his sister. His behavior is extremely aggressive with the other children
on the unit. Using a behavior modification approach with positive
reinforcement, design a treatment plan for this child.
– Assess what activities he enjoys. Set up a token system – when he displays nonaggressive
behavior, he earns a token good towards participating in the activity
selected. He loses a token when he becomes aggressive.
5. The 10 yr. old, his sister, mother, and the mother’s live in boyfriend are asked to
attend a therapy meeting. Who is the “client” that will be treated during this
– The entire family.
6. A 66 yr. old woman is admitted to the psychiatric unit with agitated depression.
She has not responded to antidepressants in the past. What would be the
medical treatment of choice for this client?
– Electroconvulsive therapy (ECT).
7. Describe the nurse’s role in preparing clients for electroconvulsive therapy
– Give accurate, non-judgmental information about the treatment. Explore client’s
concerns. Administer the following as ordered: Atropine sulfate to dry oral
secretions, a quick-acting barbiturate to induce anesthesia such as Brevital Sodium,
and a muscle relaxant such as Anectine. Check emergency equipment and O2 are
8. Describe the nursing interventions used to care for a client during and after
– Maintain patent airway. Check vital signs every 15 minutes until alert. Remain with
client following treatment until conscious. Reorient, if confused.
1. State 5 autonomic responses to anxiety.
– Shortness of breath, heart palpitations, dizziness, diaphoresis, frequent urination.
2. Identify the defense mechanism used by a person who feels guilty about
masturbating as a child, and develops a hand-washing compulsion as an adult.
3. Identify anxiety-reducing strategies the nurse can teach.
– Deep breathing techniques, visualization, relaxation techniques, exercise,
4. Which levels of anxiety facilitate learning?
– Mild to moderate.
5. A Vietnam veteran is plagued by nightmares and is found trying to strangle his
roommate one night. List, in order of priority, the appropriate nursing
– Protect roommate from harm. Stay with client. If the client is agitated, administer
anti-anxiety medications as ordered. Arrange for private room. Place client on
homicidal precautions at night.
6. A client displays a phobic response to flying. Describe the desensitization
process, which would probably be implemented.
– Talk about planes. Look at pictures of planes. Make plans to accompany client
during a visit to airport. Accompany client into a plane. Allow the client to board a
plane alone. Accompany the client on a short flight while listening to a relaxation
7. A client is in the middle of an extensive ritual, which focuses on food during
lunch. However, the client is scheduled for group therapy, which is about to
start. What action should the nurse take?
– Allow client to complete the ritual. Discuss with the group leader the possibility of
allowing the client to enter the group late. Arrange for client to begin lunch either so
that the ritual can be completed prior to scheduled activities.