Psychiatric Mental Health Nursing NCLEX Questions and Answers, Exams of Nursing

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Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain - correct answer A. Seizures Rationale: Seizures are the most common adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects includer shivering, anxiety, and chest pain. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day - correct answer C. Identify anxiety-causing situations

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Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situation as that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment. A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: A. Check on the client frequently at irregular intervals throughout the night B. Assure the client that the nurse will hold in confidence anything the client says C. Repeatedly discuss previous suicide attempts with the client D. Disregard decreased communication by the client because this is common in suicidal clients - correct answer A. Check on the client frequently at irregular intervals throughout the night

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Rationale: Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse's or seek attention for having a secret suicide plan. Option C may reinforce a suicidal idea. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it. Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. deferoxamine mesylate B. succimer (Chemet) C. flumazenil (Romazicon) D. acetylcysteine (Mucomyst) - correct answer D. acetylcysteine (Mucomyth) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate is the antidote for iron intoxication. Succimer is

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an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium) - correct answer D. clordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administer to treat seizures if they occur during the withdrawal. During postprandial monitor, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I

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was still able to purge. Today, my goal is to do it twice." What is the nurse's BEST responses? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." - correct answer D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Rationale: This response acknowledges that the clients is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self- induced eyes is. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.

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A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your past job for missing too may days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?" - correct answer B. "You told me you got fired from your past job for missing too many days after taking drugs all night." Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self- disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussing should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

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For a female client with anorexia nervosa, the nurse is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake B. The client will make a contract with the nurse that sets a target weight C. The client will identify self-perceptions about body size as unrealistic D. The client will verbalize the possible psychological consequences of self-starvation - correct answer A. The client will establish adequate daily nutritional intake Rationale: According to Maslow's Hierarchy of Needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (option C), and potential complications (option D). When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?

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A. The injury isn't consistent with the history or the child's age B. The mother and father tell different stories regarding what happened C. The family is poor D. The parents are argumentative and demanding with emergency department personnel - correct answer A. The injury isn't consistent with the history or the child's age Rationale: When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story with different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child. For a female client with anorexia nervosa, the nurse plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?

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A. They tend to overprotects their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children - correct answer A. They tend to overprotect their children Rationale: Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristic described in options B, C, and D isn't typical of parents of children with anorexia. In the emergency department, a client with a facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance

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C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry - correct answer The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband s what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the saturation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal

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C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count - correct answer C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Rationale: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department. The nurse is assigned to care for a suicidal client. Which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergy person to discuss the moral implications of suicide - correct answer B. Exploring the nurse's own feelings about suicide

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Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal clients; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicidal to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy;' however, conducting such an assessment isn't a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergy person may increase the client's trust or alleviate guilt; however, it isn't the highest priority. A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings B. Focus discussions on food and weight C. Avoid discussing unrealistic cultural standards regarding weight D. Provide objective data and feedback regarding the client's weight and attractiveness - correct answer D.

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Provide objective data and feedback regarding the client's weight and attractiveness Rationale: By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions and feelings wouldn't help her identify, accept, and work through them. Focusing discussions on food and weight would the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese - correct answer B. Aftershave lotion Rationale: Disulfiram may be given to client with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol,

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inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can product a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety - correct answer C. Set up a strict eating plan for the client Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's

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care. The client should be monitored during meals - not given privacy. Exercise should be limited and supervised. The nurse is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationships (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization - correct answer B. Readiness to leave the perpetrator and knowledge or resources Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in person's seeking or causing abusive relationships.

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A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup D. A below-normal serum potassium level - correct answer B. Thiamine deficiency Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of Vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through dietary and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.

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A parents brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably thoughout the examination B. The child pulls away from contact with the physician C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse - correct answer C. The child doesn't cry when the shoulder is examined Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by the healthcare professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers. When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority? A. Client's physical needs

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B. Client's safety needs C. Clients psychosocial needs D. Client's medical needs - correct answer B. The client's safety needs Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs are met, the client's physical, psychosocial, and medical needs can be met. The nurse is aware that which outcome criteria would be appropriate for a child diagnosed with oppositional defiance disorder? A. Accept the responsibility for own behaviors B. Be able to verbalize own needs and assert rights C. Set firm and consistent limits with the client D. Allow the client to establish his own limits and boundaries - correct answer A. Accept the responsibility for own behaviors Rationale: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions.

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Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B in incorrect as the oppositional child usually focuses on his own needs. A male client is found, sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? A. Enter the room quietly and move beside her to assess her injuries B. Call for staff back-up before entering the room and restraining her C. Move as much glass away from her and possible and sit next to her quietly D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her - correct answer D. Approach her slowly while speaking in a calm, voice, calling her name, and telling her that the nurse is here to help her

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Rationale: Ensuring the safety of the client and nurse is the priority at this time. Therefore the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that the nurse is here to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat or request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing the nurse's presence and assessing the dangers of the situation. A female client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals that the client is 5'8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should the nurse include in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight

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C. Confronting the client about her actual appearance during one-on-one sessions, schedule during each shift D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy - correct answer D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy Rationale: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image. Eighteen hours after undoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6 F (38.7 C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mmHg. The client exhibits gross hand tremors and is screening for someone to kill the bugs in the bed. The nurse should suspect: A. A postoperative infection B. Alcohol withdrawal

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C. Acute sepsis D. Pneumonia - correct answer The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complication, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course. Clonidine (Catapres) can used to treat conditions other than hypertension. The nurse is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal - correct answer C. Opiate withdrawal Rationale: Clonidine is used as adjective therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.

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A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal cheats pain. The electrocardiography (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, the nurse expects the physician to prescribe: A. Lidocaine (Xylocaine) B. Procainamide (Pronestyl) C. Nitroglycerin (Nitro-Bid IV) D. Epinephrine - correct answer C. Nitroglycerin (Nitro- Bid IV) Rationale: The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or a systole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potential even its adrenergic effects.

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A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'nm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated." - correct answer C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror.

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Proffering fast food over health food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in this client with anorexia nervosa. The nurse is aware that drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil) - correct answer C. Haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome. A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse? A. "Why didn't you get someone else to drive?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive."