NCLEX PN 3000 Foundations of Psychiatric Nursing Latest Update 2023, Exams of Nursing

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The nurse is documenting a plan of care for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

1. Monitoring the client's vital signs every hour for 4 hours
2. Placing the client in Trendelenburg's position
3. Encouraging early ambulation
4. Reorienting the client to time and place ✅Correct Answer : 4 Your Answer: 1 RATIONALES: Confusion and temporary memory loss are the most common adverse effects of ECT. The nurse should continually reorient the client to time and place as he wakes up from the procedure. Following ECT, the nurse should monitor the client's vital signs every 15 minutes for the first hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?"
5. "You may leave the hospital at any time unless you are suicidal."

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2. "Let's talk more after the health team has assessed you."
3. "Once you've signed the papers, you have no say."
4. "Because you could hurt yourself, you must be safe before being discharged."
5. "You need a lawyer to help you make that decision."
6. "There must be a court hearing before you leave the hospital." ✅Correct Answer : 1,2,4 Your Answer: 2, RATIONALES: A person who is admitted to a psychiatric hospital on a voluntary basis may sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Option 3 is incorrect because it denies the client's rights; option 5 is incorrect because the client doesn't need a lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't mandated before discharge. A hearing is held only if the client remains unsafe and requires further treatment. A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his

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laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on:

1. consistently enforcing unit rules and facility policy.
2. isolating the client to decrease contact with easily manipulated clients.
3. engaging in power struggles with the client to minimize manipulative behavior.
4. using behavior modification to decrease negative behavior by using negative reinforcement. ✅Correct Answer : 1 Your Answer: 3 RATIONALES: Firmness and consistency regarding rules are the hallmarks of a plan of care for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people. Behavior modification usually fails because of staff inconsistency and client manipulation. A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. This client is demonstrating which behavior?
5. Confidentiality

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2. Splitting
3. Empathy
4. Gnawing ✅Correct Answer : 2 Your Answer: 1 RATIONALES: In splitting, the client manipulates the staff in attempt to create conflicts between staff members. Boundaries must be set to limit the client's negative behavior. Confidentiality is the protection of client information. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. Gnawing isn't a term used in psychiatric nursing. A client is prescribed bupropion (Wellbutrin) to treat depression. The nurse should monitor the client for which adverse reactions associated with bupropion therapy? Select all that apply:
5. Seizures
6. Anxiety

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3. Insomnia
4. Diarrhea
5. Bradycardia ✅Correct Answer : 1,2,3 Your Answer: 1,3, RATIONALES: Adverse effects to bupropion include seizures, anxiety, insomnia, tachycardia (not bradycardia), and hypertension or hypotension. Diarrhea isn't an adverse effect of bupropion therapy. During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose is to evaluate the client's ability to think:
6. rationally.
7. concretely.
8. abstractly.
9. tangentially. ✅Correct Answer : 3 Your Answer: 1

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RATIONALES: Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, not goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense such as "Even if you spill your milk, you shouldn't cry about it." A client suffering posttraumatic stress disorder is prescribed sertraline (Zoloft), 50 mg by mouth once daily. Which actions should the nurse take when administering this drug? Select all that apply:

1. Administer the drug at bedtime.
2. Mix the oral concentrate with 4 oz (120 ml) of water, ginger ale, or lemon-lime soda.
3. Administer the oral solution immediately after dilution.

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4. Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations.
5. Advise the client to use caution when performing hazardous tasks that require alertness. ✅Correct Answer : 2,3,4, RATIONALES: Sertraline should be administered once daily, either in the morning or evening (but not at bedtime). The oral concentrate should be mixed with 4 oz of water, ginger ale, or lemon-lime soda, and it should be administered immediately after mixing. The client should be advised to check with the prescriber or pharmacist before taking any over-the-counter preparations. The nurse should also advise the client to use caution when performing hazardous tasks that require alertness. The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair? ✅Correct Answer : 1 Your Answer: 3 RATIONALES: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg. The nurse is administering two drugs concomitantly to a client. Which interaction occurs when two drugs with the same qualitative effects produce a response when given together that's greater than the response either drug produces when given alone?
6. Tolerance

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2. Antagonism
3. Hyporeactivity
4. Synergism ✅Correct Answer : 4 Your Answer: 1 RATIONALES: Synergism, or a synergistic effect, occurs when two drugs with the same qualitative effects produce a response when given together greater than either drug produces when given alone. Tolerance is a decreased response or decreased sensitivity of the receptor to a drug. Antagonism occurs when the combined response to two drugs given together is less than the response either drug produces when given alone. Hyporeactivity is a less-than-usual response to a normal drug dose. A client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?
5. It's a measure of effect, not a standard measure of weight or quantity.
6. It's the smallest measurement in the apothecary system.
7. It's the basis for solids in the avoirdupois system.

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4. It's a common measurement in the metric system. ✅Correct Answer : 1 Your Answer: 3 RATIONALES: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids and the gram is used for solids. The nurse is collecting admission data from a newly admitted client. Which question should the nurse include when asking the client about orthopnea? ✅Correct Answer : 4 Your Answer: 3 RATIONALES: The nurse should ask the client with orthopnea (shortness of breath while lying down) how many pillows he uses. Option 1 should be used when questioning the client about hemoptysis. Options 2 and 3 should be used when asking a client about pain What is the only advantage of using a floor stock system?
5. The nurse can implement medication orders quickly.
6. The nurse receives input from the pharmacist.

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3. The system minimizes transcription errors.
4. The system reinforces accurate calculations. ✅Correct Answer : 1 Your Answer: 2 RATIONALES: A floor stock system enables the nurse to implement medication orders quickly. However, this method is considered unsafe because it doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
5. Semi-Fowler's
6. Supine
7. High-Fowler's
8. Side-lying ✅Correct Answer : 4 Your Answer: 3 RATIONALES: Because of lethargy, the posttonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side- lying position until he's fully awake is best. The semi-Fowler, supine, and high-

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Fowler positions don't allow for adequate oral drainage of a lethargic posttonsillectomy client and increase the risk of blood aspiration.