NCLEX - MENTAL HEALTH Day1 (Part 2)

A new nurse assesses gender identity of an adolescent transgender client. What’s the appropriate question?

• Do you prefer being referred to as 'he' or 'she'?
• How would you describe your gender?
• What gender were you originally?
• What is your preferred name?

Answer explanation

Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust. Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to determine clients’ gender identity by asking open-ended questions that allow clients to explain their identities in their own words (Option 2). (Option 1) The client may not identify as simply male or female. Asking closed-ended questions (eg, whether the client prefers “he” or “she”) does not allow for client elaboration. (Option 3) Because the client does not identify with the gender designated at birth, referring to a transgender client’s “original gender” may cause distress and discomfort. The nurse should instead ask what sex the client was assigned on the original birth certificate. (Option 4) Asking “What is your preferred name?” is not open-ended and does not thoroughly assess gender identity. However, the client’s preferred and legal names may be different. The nurse should use the client’s preferred name to show respect and to develop a therapeutic relationship.

A 7-year-old with ADHD becomes aggressive. Which action is the priority?

• Ask the client to blow up a balloon
• Administer a PRN dose of methylphenidate
• Place the client in a quiet room with supervision
• Reinforce consequences of disruptive behavior

Answer explanation

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, distractibility, and/or hyperactivity. A diagnosis of ADHD can be made when a child (age ≤17) exhibits multiple symptoms of hyperactivity/impulsiveness and/or inattentiveness (eg, difficulty maintaining focus) for at least 6 months. Some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and... When caring for a child experiencing excessive hyperactivity and impulsivity, the nurse should prioritize safety by removing the client from the source of frustration (eg, other children) and placing the child in a low-stimulus environment with supervision. A quiet room helps the child regain self-control and ensures safety. Children should have a safe space to work through feelings of frustration with support from staff (Option 3). (Option 1) Asking the child to blow up a balloon provides an easy mode of distraction; however, the priority is ensuring safety. (Option 2) Methylphenidate is not used as a PRN medication and should be given on daily basis for optimal symptom control. (Option 4) The child’s anger limits comprehension; therefore, discussing the consequences of inappropriate behavior is indicated once the child is calm.

A client presents with bruises, facial lacerations, and a possibly fractured arm. The spouse is angry at bedside. What should the nurse do first?

• Refer to social services
• Talk to the client privately without the spouse
• Prepare client for an x-ray
• Cleanse and suture facial wounds

Answer explanation

Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against the other in an intimate relationship to maintain power and control. Physical signs concerning for abuse include bruises and fractures in various stages of healing. The priority intervention for clients who experience IPV is to remove any source of immediate danger. Clients should be interviewed in a private setting, so the suspected abuser is unable to guide the client’s answers or intimidate the client from providing truthful responses (Option 2). The nurse should ask nonjudgmental questions and focus on establishing trust; this will allow the client to feel comfortable enough to disclose any potential abuse at the client’s own pace. (Option 1) Referring the client to social services should occur with the client’s permission after any immediate threats are removed and physiological needs are met. This should not be done in the presence of any potential abusers. (Options 3 and 4) The nurse should follow facility guidelines for documenting, gathering evidence, and/or photographing injuries. The nurse should treat the client’s injuries after ensuring client safety.

Spouse of a client with borderline personality disorder says the client self-harms to prevent business travel. What should nurse say?

• Cancel your business trip.
• Your spouse should come to the clinic today.
• It sounds like you're having a difficult time.
• Ignore the behavior; it's for attention.

Answer explanation

Borderline personality disorder (BPD) is characterized by intense impulsivity and emotional dysregulation combined with unstable relationships and self-image. Clients with BPD fear rejection and abandonment. To avoid abandonment, clients use manipulation and control, often unconsciously. Manipulative behavior may be of a positive nature (eg, the use of flattery) or a negative nature (eg, self-harm behaviors). Clients with BPD are at an increased risk for suicidal ideation. The nurse should take all suicidal behavior (eg, self-inflicted lacerations) seriously and immediately assess the client in a secure environment to promote client safety (Option 2). The nurse should ask the client directly about thoughts of suicide, including the level of intent, plan for suicide, and methods the client may use. (Option 1) Telling the spouse to cancel the business trip does not address the client’s safety. In addition, this response may negate the spouse’s feelings about the situation. (Option 3) The nurse should prioritize the client’s safety. Once the client is in a safe environment and suicidal ideation has been assessed, the nurse can provide support to the client’s spouse. (Option 4) The client’s behavior should not be ignored because self-harm behavior demonstrates an enhanced risk for suicide.

Which statement is true of narcissistic personality disorder (NPD)?

• Fear of abandonment and fragile self-esteem
• May require meds for hallucinations
• Magical thinking and depersonalization
• Episodes of acute anxiety

Answer explanation

Narcissistic personality disorder (NPD) is characterized by a recurrent pattern of grandiosity (ie, inflated sense of self-importance and superiority), need for admiration, and lack of empathy. Clients with NPD are hypersensitive to criticism and may project superiority, arrogance, and independence to hide their true sense of self. Narcissistic traits often derive from a distorted view of oneself that develops from childhood neglect or criticism. Clients with NPD often have an extremely fragile self-esteem. These clients develop characteristics of self-importance to protect themselves, improve self-esteem, and minimize their fear of abandonment (Option 1). Characteristics of NPD are rigid and pervasive because clients often lack the understanding that these traits are problematic. (Option 2) Hallucinations are often experienced by clients with schizophrenia, not NPD. Antipsychotic medications (eg, olanzapine, ziprasidone) are used to manage hallucinations, delusions, and other symptoms of schizophrenia. (Option 3) Clients with schizotypal personality disorder often demonstrate magical thinking, ideas of reference, and feelings of depersonalization. (Option 4) Episodes of acute anxiety are associated with anxiety and panic disorders, not NPD.