NCLEX PSYCH TEST 2 Questions and Answers
1.The nurse is to administer Xanax (alprazolam) to help a client of Japan-
ese descent calm down. The order reads Xanax 0.25 to 1 mg by mouth as
needed for agitation. What is the best dose for the nurse to give this
client?
mg.
ANS 2 mg.
Asians have a greater sensitivity to psychotropic medication and
generally require much less than other cultural groups to achieve
positive results. The smallest dose is safest to start; the dosage can
always be increased. However, a dose that is too high for the client is
likely to cause unpleasant or even serious side effects. Those side
effects likely would lead to distress and noncompliance in the future.
2.A client is taking diazepam (Valium) for generalized anxiety disorder.
Which instruction should the nurse give to this client? Select all that apply.
1. To consult with his health care provider before he stops taking the drug.
2. To avoid eating cheese and other tyramine-rich foods. 3. To take the
med- ication on an empty stomach.
4. Not to use alcohol while taking the drug.
5. To stop taking the drug if he experiences swelling of the lips and face
and difficulty breathing.
ANS 1, 4, 5.
The nurse should instruct the client who is taking diazepam to take the
,medication as prescribed; stopping the medication suddenly can cause
withdrawal symptoms. This medication is used for a short term only.
The drug dose can be potentiated by alcohol and the client should not
drink alcoholic beverages while taking this drug. Swelling of the lips and
face and difficulty breathing are signs and symptoms of an allergic
reaction. The client should stop taking the drug and seek medical
assistance immediately. The client does not need to avoid eating foods
containing tyramine; tyramine interacts with monoamine oxidase
inhibitors, not Valium. The client can take the medication with food.
3.An adult client diagnosed with anxiety disorder becomes anxious when
she touches fruits and vegetables. What should the nurse do?
1. Instruct the woman to avoid touching these foods.
2. Ask the woman why she becomes anxious in these situations.
3. Assist the woman to make a plan for her family to do the food shopping
and preparation.
4. Teach the woman to use cognitive behavioral approaches to manage
her anxiety.
ANS 4.
Cognitive behavioral therapy is effective in treating anxiety disorders.
The nurse can assist the client in identifying the onset of the fears that
cause the anxiety and develop strategies to modify the behavior
associated with the fears. Avoiding touching foods, asking about
reasons for the anxiety, and providing ways to work
around touching the foods do not deal with the anxiety and are not
,interventions that will help this client.
4.A client who is pacing and wringing his hands states, "I just need to walk"
when questioned by the nurse about what he is feeling. Which of the
following responses by the nurse is most therapeutic?
1. "You need to sit down and relax."
2. "Are you feeling anxious?"
3. "Is something bothering you?"
4. "You must be experiencing a problem now."
ANS 2.
Asking, "Are you feeling anxious?" helps the client to specifically label
the feeling as anxiety so that he can begin to understand and manage
it. Some clients need assistance with identifying what they are feeling
so they can recognize what is happening to them. Stating, "You need to
sit down and relax," is not appropriate because the client needs to
continue his pacing to feel better. Asking if something is bothering the
client or saying that he must be experiencing a problem is vague and
does not help the client identify his feelings as anxiety.
5.A client is brought to the emergency department by his brother. The client
is perspiring profusely, breathing rapidly, and complaining of dizziness and
palpitations. Problems of a cardiovascular nature are ruled out, and the
client's diagnosis is tentatively listed as a panic attack. After the symptoms
pass, the client states, "I thought I was going to die." Which of the following
responses by the nurse is best?
, 1. "It was very frightening for you."
2. "We would not have let you die."
3. "I would have felt the same way."
4. "But you're okay now."
ANS 1.
The nurse responds with the statement, "It was very frightening for
you," to express empathy, thus acknowledging the client's discomfort
and accepting his feelings. The nurse conveys respect and validates the
client's self-worth. The other statements do not focus on the client's
underlying feelings, convey active listening, or promote trust.
6.Which of the following points should the nurse include when teaching
a client about panic disorder?
1. Staying in the house will eliminate panic attacks.
2. Medication should be taken when symptoms start.
3. Symptoms of a panic attack are time limited and will abate.
4. Maintaining self-control will decrease symptoms of panic.
ANS 3.
It is important for the nurse to teach the client that the symptoms of a
panic attack are time limited and will abate. This helps decrease the
client's fear about what is
occurring. Clients benefit from learning about their illness, what
symptoms to expect, and the helpful use of medication. A simple
biologic explanation of the disorder can convince clients to take their
medication. Telling the client to stay in the house to eliminate panic
1.The nurse is to administer Xanax (alprazolam) to help a client of Japan-
ese descent calm down. The order reads Xanax 0.25 to 1 mg by mouth as
needed for agitation. What is the best dose for the nurse to give this
client?
mg.
ANS 2 mg.
Asians have a greater sensitivity to psychotropic medication and
generally require much less than other cultural groups to achieve
positive results. The smallest dose is safest to start; the dosage can
always be increased. However, a dose that is too high for the client is
likely to cause unpleasant or even serious side effects. Those side
effects likely would lead to distress and noncompliance in the future.
2.A client is taking diazepam (Valium) for generalized anxiety disorder.
Which instruction should the nurse give to this client? Select all that apply.
1. To consult with his health care provider before he stops taking the drug.
2. To avoid eating cheese and other tyramine-rich foods. 3. To take the
med- ication on an empty stomach.
4. Not to use alcohol while taking the drug.
5. To stop taking the drug if he experiences swelling of the lips and face
and difficulty breathing.
ANS 1, 4, 5.
The nurse should instruct the client who is taking diazepam to take the
,medication as prescribed; stopping the medication suddenly can cause
withdrawal symptoms. This medication is used for a short term only.
The drug dose can be potentiated by alcohol and the client should not
drink alcoholic beverages while taking this drug. Swelling of the lips and
face and difficulty breathing are signs and symptoms of an allergic
reaction. The client should stop taking the drug and seek medical
assistance immediately. The client does not need to avoid eating foods
containing tyramine; tyramine interacts with monoamine oxidase
inhibitors, not Valium. The client can take the medication with food.
3.An adult client diagnosed with anxiety disorder becomes anxious when
she touches fruits and vegetables. What should the nurse do?
1. Instruct the woman to avoid touching these foods.
2. Ask the woman why she becomes anxious in these situations.
3. Assist the woman to make a plan for her family to do the food shopping
and preparation.
4. Teach the woman to use cognitive behavioral approaches to manage
her anxiety.
ANS 4.
Cognitive behavioral therapy is effective in treating anxiety disorders.
The nurse can assist the client in identifying the onset of the fears that
cause the anxiety and develop strategies to modify the behavior
associated with the fears. Avoiding touching foods, asking about
reasons for the anxiety, and providing ways to work
around touching the foods do not deal with the anxiety and are not
,interventions that will help this client.
4.A client who is pacing and wringing his hands states, "I just need to walk"
when questioned by the nurse about what he is feeling. Which of the
following responses by the nurse is most therapeutic?
1. "You need to sit down and relax."
2. "Are you feeling anxious?"
3. "Is something bothering you?"
4. "You must be experiencing a problem now."
ANS 2.
Asking, "Are you feeling anxious?" helps the client to specifically label
the feeling as anxiety so that he can begin to understand and manage
it. Some clients need assistance with identifying what they are feeling
so they can recognize what is happening to them. Stating, "You need to
sit down and relax," is not appropriate because the client needs to
continue his pacing to feel better. Asking if something is bothering the
client or saying that he must be experiencing a problem is vague and
does not help the client identify his feelings as anxiety.
5.A client is brought to the emergency department by his brother. The client
is perspiring profusely, breathing rapidly, and complaining of dizziness and
palpitations. Problems of a cardiovascular nature are ruled out, and the
client's diagnosis is tentatively listed as a panic attack. After the symptoms
pass, the client states, "I thought I was going to die." Which of the following
responses by the nurse is best?
, 1. "It was very frightening for you."
2. "We would not have let you die."
3. "I would have felt the same way."
4. "But you're okay now."
ANS 1.
The nurse responds with the statement, "It was very frightening for
you," to express empathy, thus acknowledging the client's discomfort
and accepting his feelings. The nurse conveys respect and validates the
client's self-worth. The other statements do not focus on the client's
underlying feelings, convey active listening, or promote trust.
6.Which of the following points should the nurse include when teaching
a client about panic disorder?
1. Staying in the house will eliminate panic attacks.
2. Medication should be taken when symptoms start.
3. Symptoms of a panic attack are time limited and will abate.
4. Maintaining self-control will decrease symptoms of panic.
ANS 3.
It is important for the nurse to teach the client that the symptoms of a
panic attack are time limited and will abate. This helps decrease the
client's fear about what is
occurring. Clients benefit from learning about their illness, what
symptoms to expect, and the helpful use of medication. A simple
biologic explanation of the disorder can convince clients to take their
medication. Telling the client to stay in the house to eliminate panic
