🎯 High-Yield Points for This Topic
- Therapeutic communication: use open-ended questions, reflection, clarification; avoid false reassurance
- Safety first: suicidal ideation = highest priority; remove sharp objects, ensure constant observation
- Schizophrenia: antipsychotics; monitor for EPS (extrapyramidal symptoms) and tardive dyskinesia
- MAOI diet restriction: avoid tyramine-containing foods (aged cheese, wine, cured meats)
- Involuntary commitment: requires imminent danger to self or others; not just refusal of treatment
[Infographic: Mental Health NCLEX Questions Key Concepts — Clinical Manifestations, Nursing Interventions, Priority Actions]
Practice Questions
Question 1
A client with depression states 'I've been thinking about ending it all.' Which response by the nurse is MOST therapeutic?
✓ Correct: It sounds like you have been having thoughts of suicide. Can you tell me more about what you are experiencing?
When a client makes a statement that may indicate suicidal ideation, the nurse should address it directly and therapeutically. Asking 'Can you tell me more?' opens dialogue, validates the client's experience, and allows for risk assessment. Asking directly about suicide does NOT plant the idea — this is a myth. False reassurance ('things will get better'), minimising ('many people feel that way'), and moralising ('you shouldn't think that way') are all non-therapeutic responses.
When a client makes a statement that may indicate suicidal ideation, the nurse should address it directly and therapeutically. Asking 'Can you tell me more?' opens dialogue, validates the client's experience, and allows for risk assessment. Asking directly about suicide does NOT plant the idea — this is a myth. False reassurance ('things will get better'), minimising ('many people feel that way'), and moralising ('you shouldn't think that way') are all non-therapeutic responses.
Question 2
A nurse is caring for a client with schizophrenia who reports that their tongue keeps protruding involuntarily. Which action is MOST appropriate?
✓ Correct: Document the finding and notify the provider immediately as this may indicate tardive dyskinesia
Involuntary tongue movements are a sign of tardive dyskinesia — a potentially irreversible movement disorder caused by long-term antipsychotic use. This requires immediate reporting to the provider, as the medication may need to be changed. Tardive dyskinesia involves involuntary repetitive movements of the face, tongue, and extremities. It is NOT normal and cannot be controlled voluntarily. Administering more antipsychotic would worsen it.
Involuntary tongue movements are a sign of tardive dyskinesia — a potentially irreversible movement disorder caused by long-term antipsychotic use. This requires immediate reporting to the provider, as the medication may need to be changed. Tardive dyskinesia involves involuntary repetitive movements of the face, tongue, and extremities. It is NOT normal and cannot be controlled voluntarily. Administering more antipsychotic would worsen it.
Question 3
A client in an acute psychiatric unit is pacing and states 'I feel like I am going to explode.' Which action is the PRIORITY?
✓ Correct: Approach calmly, speak in a low tone, offer a quiet environment and de-escalation
De-escalation is the first-line intervention for an escalating client. Approach calmly, use a low non-threatening voice, acknowledge their distress, offer choices, and move them to a quieter environment. Physical restraints are a LAST RESORT after all other de-escalation measures fail, due to serious safety risks (asphyxia, injury). Leaving the client alone is not therapeutic. Calling a code when verbal de-escalation has not been attempted is premature.
De-escalation is the first-line intervention for an escalating client. Approach calmly, use a low non-threatening voice, acknowledge their distress, offer choices, and move them to a quieter environment. Physical restraints are a LAST RESORT after all other de-escalation measures fail, due to serious safety risks (asphyxia, injury). Leaving the client alone is not therapeutic. Calling a code when verbal de-escalation has not been attempted is premature.
Question 4
A client taking phenelzine (MAOI antidepressant) is being discharged. Which food does the nurse instruct the client to AVOID?
✓ Correct: Aged cheddar cheese
MAOIs inhibit monoamine oxidase, the enzyme that metabolises tyramine. Eating tyramine-rich foods (aged cheeses, cured meats, red wine, fermented products) causes tyramine accumulation, leading to a hypertensive crisis — a life-threatening emergency with severe headache and BP spike. Fresh chicken, rice, and vegetables are safe. Aged cheese is a classic high-tyramine food that must be strictly avoided.
MAOIs inhibit monoamine oxidase, the enzyme that metabolises tyramine. Eating tyramine-rich foods (aged cheeses, cured meats, red wine, fermented products) causes tyramine accumulation, leading to a hypertensive crisis — a life-threatening emergency with severe headache and BP spike. Fresh chicken, rice, and vegetables are safe. Aged cheese is a classic high-tyramine food that must be strictly avoided.
Question 5
A client with anorexia nervosa is being reintroduced to oral feeding. Which nursing action is MOST important initially?
✓ Correct: Monitor the client for 1 hour after each meal to prevent purging
Preventing purging after meals is the highest priority safety intervention for a client with anorexia nervosa who is refeeding. The nurse or a staff member must stay with or monitor the client for at least 1 hour post-meal to prevent self-induced vomiting. Without this safeguard, the refeeding programme is ineffective. The other interventions are appropriate but secondary to preventing purging.
Preventing purging after meals is the highest priority safety intervention for a client with anorexia nervosa who is refeeding. The nurse or a staff member must stay with or monitor the client for at least 1 hour post-meal to prevent self-induced vomiting. Without this safeguard, the refeeding programme is ineffective. The other interventions are appropriate but secondary to preventing purging.
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[Clinical Concept Map: Mental Health NCLEX Questions — Pathophysiology, Assessment Findings, Nursing Actions]