Psychiatric Mental Health Nursing NCLEX f f f f f
Questions (50 Questions) f f
Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam
f f f f f f f f f f f f f f
(Serax). Before administering the medication, the nurse should be prepared for which
f f f f f f f f f f f f
common adverse effect? f f
A. Seizures
f
B. Shivering
f
C. Anxiety f
D. Chest pain - A. Seizures
f f f f f
Rationale: Seizures are the most common adverse effect of using flumazenil to reverse
f f f f f f f f f f f f f
benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic f f f f f f f f f f f f f
antidepressant and benzodiazepine overdose. Less common adverse effects includer f f f f f f f f f
shivering, anxiety, and chest pain. f f f f
The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a
f f f f f f f f f f f f f f f f f
client diagnosed with bulimia is to:
f f f f f
A. Avoid shopping for large amounts of food
f f f f f f f
B. Control eating impulses
f f f
C. Identify anxiety-causing situations
f f f
D. Eat only three meals per day - C. Identify anxiety-causing situations
f f f f f f f f f f f
Rationale: Bulimic behavior is generally a maladaptive coping response to stress and
f f f f f f f f f f f f
underlying issues. The client must identify anxiety-causing situation as that stimulate the
f f f f f f f f f f f f
bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for
f f f f f f f f f f f f f f f
large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing
f f f f f f f f f f f f f f f
them with adaptive coping mechanisms can be integrated into the plan of care after initially
f f f f f f f f f f f f f f f
addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early
f f f f f f f f f f f f f f f
in treatment.
f
A female client who's at high risk for suicide needs close supervision. To best ensure the
f f f f f f f f f f f f f f f f
client's safety, the nurse should:
f f f f
,A. Check on the client frequently at irregular intervals throughout the night
f f f f f f f f f f f
B. Assure the client that the nurse will hold in confidence anything the client says
f f f f f f f f f f f f f f
C. Repeatedly discuss previous suicide attempts with the client
f f f f f f f f
D. Disregard decreased communication by the client because this is common in suicidal
f f f f f f f f f f f f f
clients - A. Check on the client frequently at irregular intervals throughout the night
f f f f f f f f f f f f f
Rationale: Checking the client frequently but at irregular intervals prevents the client from f f f f f f f f f f f f f
predicting when observation will take place and altering behavior in a misleading way at these f f f f f f f f f f f f f f f
times. Option B may encourage the client to try to manipulate the nurse's or seek attention for
f f f f f f f f f f f f f f f f f
having a secret suicide plan. Option C may reinforce a suicidal idea. Decreased
f f f f f f f f f f f f f
communication is a sign of withdrawal that may indicate the client has decided to commit f f f f f f f f f f f f f f f
suicide; the nurse shouldn't disregard it. f f f f f
Which of the following drugs should the nurse prepare to administer to a client with a toxic
f f f f f f f f f f f f f f f f f
acetaminophen (Tylenol) level? f f
A. deferoxamine mesylate
f f
B. succimer (Chemet)
f f
C. flumazenil (Romazicon)
f f
D. acetylcysteine (Mucomyst) - D. acetylcysteine (Mucomyth)
f f f f f f
Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion f f f f f f f f f f f
of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate is the antidote for iron
f f f f f f f f f f f f f
intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative f f f f f f f f f f f f
effects of benzodiazepines. f f
A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the
f f f f f f f f f f f f f f f f
following medications is the nurse likely to administer to reduce the symptoms of alcohol f f f f f f f f f f f f f f
withdrawal?
A. naloxone (Narcan)
f f
B. haloperidol (Haldol)
f f
C. magnesium sulfate
f f
D. chlordiazepoxide (Librium) - D. clordiazepoxide (Librium)
f f f f f f
Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of f f f f f f f f f f f
alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe
f f f f f f f f f f f f f
agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium f f f f f f f f f f f
sulfate and other anticonvulsant medications are only administer to treat seizures if they occur
f f f f f f f f f f f f f f
during the withdrawal. f f
During postprandial monitor, a female client with bulimia nervosa tells the nurse, "You can sit
f f f f f f f f f f f f f f f
with me, but you're just wasting your time. After you sat with me yesterday, I was still able to
f f f f f f f f f f f f f f f f f f f
purge. Today, my goal is to do it twice." What is the nurse's BEST responses?
f f f f f f f f f f f f f f
A. "I trust you not to purge."
f f f f f f
B. "How are you purging and when do you do it?"
f f f f f f f f f f
C. "Don't worry. I won't allow you to purge today."
f f f f f f f f f
D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
f f f f f f f f f f f f f f f f f f f f f
- D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you
f f f f f f f f f f f f f f f f f f f f f
eat."
, Rationale: This response acknowledges that the clients is testing limits and that the nurse is f f f f f f f f f f f f f f f
setting them by performing postprandial monitoring to prevent self-induced eyes is. Clients
f f f f f f f f f f f f
with bulimia nervosa need to feel in control of the diet because they feel they lack control over all
f f f f f f f f f f f f f f f f f f
other aspects of their lives. Because their therapeutic relationships with caregivers are less
f f f f f f f f f f f f f f
important than their need to purge, they don't fear betraying the nurse's trust by engaging in the f f f f f f f f f f f f f f f f f
activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or
f f f f f f f f f f f f f f f
challenging response may trigger a power struggle between the nurse and client. f f f f f f f f f f f
A male client admitted to the psychiatric unit for treatment of substance abuse says to the
f f f f f f f f f f f f f f f f
nurse, "It felt so wonderful to get high." Which of the following is the most appropriate
f f f f f f f f f f f f f f f f
response?
A. "If you continue to talk like that, I'm going to stop speaking to you."
f f f f f f f f f f f f f f
B. "You told me you got fired from your past job for missing too may days after taking drugs all
f f f f f f f f f f f f f f f f f f f f
night."
C. "Tell me more about how it felt to get high."
f f f f f f f f f f
D. "Don't you know it's illegal to use drugs?" - B. "You told me you got fired from your past job for
f f f f f f f f f f f f f f f f f f f f f f
missing too many days after taking drugs all night." f f f f f f f f
Rationale: Confronting the client with the consequences of substance abuse helps to break f f f f f f f f f f f f f
through denial. Making threats (option A) isn't an effective way to promote self-disclosure or
f f f f f f f f f f f f f f
establish a rapport with the client. Although the nurse should encourage the client to discuss f f f f f f f f f f f f f f f
feelings, the discussing should focus on how the client felt before, not during, an episode of
f f f f f f f f f f f f f f f f
substance abuse (option C). Encouraging elaboration about his experience while getting high f f f f f f f f f f f f
may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a
f f f f f f f f f f f f f f f f
reminder to this effect (option D) is unlikely to alter behavior. f f f f f f f f f f
For a female client with anorexia nervosa, the nurse is aware that which goal takes the highest
f f f f f f f f f f f f f f f f f
priority?
A. The client will establish adequate daily nutritional intake
f f f f f f f f
B. The client will make a contract with the nurse that sets a target weight
f f f f f f f f f f f f f f
C. The client will identify self-perceptions about body size as unrealistic
f f f f f f f f f f
D. The client will verbalize the possible psychological consequences of self-starvation - A. The
f f f f f f f f f f f f f f
client will establish adequate daily nutritional intake
f f f f f f
Rationale: According to Maslow's Hierarchy of Needs, all humans need to meet basic f f f f f f f f f f f f f
physiological needs first. Because a client with anorexia nervosa eats little or nothing, the f f f f f f f f f f f f f f
nurse must first plan to help the client meet this basic, immediate physiological need. The
f f f f f f f f f f f f f f f
nurse may give lesser priority to goals that address long-term plans (as in option B), self-
f f f f f f f f f f f f f f f
perception (option C), and potential complications (option D). f f f f f f f
When interviewing the parents of an injured child, which of the following is the strongest
f f f f f f f f f f f f f f f
indicator that child abuse may be a problem? f f f f f f f
A. The injury isn't consistent with the history or the child's age
f f f f f f f f f f f
B. The mother and father tell different stories regarding what happened
f f f f f f f f f f
C. The family is poor
f f f f
D. The parents are argumentative and demanding with emergency department personnel - A.
f f f f f f f f f f f f f
The injury isn't consistent with the history or the child's age
f f f f f f f f f f
Questions (50 Questions) f f
Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam
f f f f f f f f f f f f f f
(Serax). Before administering the medication, the nurse should be prepared for which
f f f f f f f f f f f f
common adverse effect? f f
A. Seizures
f
B. Shivering
f
C. Anxiety f
D. Chest pain - A. Seizures
f f f f f
Rationale: Seizures are the most common adverse effect of using flumazenil to reverse
f f f f f f f f f f f f f
benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic f f f f f f f f f f f f f
antidepressant and benzodiazepine overdose. Less common adverse effects includer f f f f f f f f f
shivering, anxiety, and chest pain. f f f f
The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a
f f f f f f f f f f f f f f f f f
client diagnosed with bulimia is to:
f f f f f
A. Avoid shopping for large amounts of food
f f f f f f f
B. Control eating impulses
f f f
C. Identify anxiety-causing situations
f f f
D. Eat only three meals per day - C. Identify anxiety-causing situations
f f f f f f f f f f f
Rationale: Bulimic behavior is generally a maladaptive coping response to stress and
f f f f f f f f f f f f
underlying issues. The client must identify anxiety-causing situation as that stimulate the
f f f f f f f f f f f f
bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for
f f f f f f f f f f f f f f f
large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing
f f f f f f f f f f f f f f f
them with adaptive coping mechanisms can be integrated into the plan of care after initially
f f f f f f f f f f f f f f f
addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early
f f f f f f f f f f f f f f f
in treatment.
f
A female client who's at high risk for suicide needs close supervision. To best ensure the
f f f f f f f f f f f f f f f f
client's safety, the nurse should:
f f f f
,A. Check on the client frequently at irregular intervals throughout the night
f f f f f f f f f f f
B. Assure the client that the nurse will hold in confidence anything the client says
f f f f f f f f f f f f f f
C. Repeatedly discuss previous suicide attempts with the client
f f f f f f f f
D. Disregard decreased communication by the client because this is common in suicidal
f f f f f f f f f f f f f
clients - A. Check on the client frequently at irregular intervals throughout the night
f f f f f f f f f f f f f
Rationale: Checking the client frequently but at irregular intervals prevents the client from f f f f f f f f f f f f f
predicting when observation will take place and altering behavior in a misleading way at these f f f f f f f f f f f f f f f
times. Option B may encourage the client to try to manipulate the nurse's or seek attention for
f f f f f f f f f f f f f f f f f
having a secret suicide plan. Option C may reinforce a suicidal idea. Decreased
f f f f f f f f f f f f f
communication is a sign of withdrawal that may indicate the client has decided to commit f f f f f f f f f f f f f f f
suicide; the nurse shouldn't disregard it. f f f f f
Which of the following drugs should the nurse prepare to administer to a client with a toxic
f f f f f f f f f f f f f f f f f
acetaminophen (Tylenol) level? f f
A. deferoxamine mesylate
f f
B. succimer (Chemet)
f f
C. flumazenil (Romazicon)
f f
D. acetylcysteine (Mucomyst) - D. acetylcysteine (Mucomyth)
f f f f f f
Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion f f f f f f f f f f f
of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate is the antidote for iron
f f f f f f f f f f f f f
intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative f f f f f f f f f f f f
effects of benzodiazepines. f f
A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the
f f f f f f f f f f f f f f f f
following medications is the nurse likely to administer to reduce the symptoms of alcohol f f f f f f f f f f f f f f
withdrawal?
A. naloxone (Narcan)
f f
B. haloperidol (Haldol)
f f
C. magnesium sulfate
f f
D. chlordiazepoxide (Librium) - D. clordiazepoxide (Librium)
f f f f f f
Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of f f f f f f f f f f f
alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe
f f f f f f f f f f f f f
agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium f f f f f f f f f f f
sulfate and other anticonvulsant medications are only administer to treat seizures if they occur
f f f f f f f f f f f f f f
during the withdrawal. f f
During postprandial monitor, a female client with bulimia nervosa tells the nurse, "You can sit
f f f f f f f f f f f f f f f
with me, but you're just wasting your time. After you sat with me yesterday, I was still able to
f f f f f f f f f f f f f f f f f f f
purge. Today, my goal is to do it twice." What is the nurse's BEST responses?
f f f f f f f f f f f f f f
A. "I trust you not to purge."
f f f f f f
B. "How are you purging and when do you do it?"
f f f f f f f f f f
C. "Don't worry. I won't allow you to purge today."
f f f f f f f f f
D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
f f f f f f f f f f f f f f f f f f f f f
- D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you
f f f f f f f f f f f f f f f f f f f f f
eat."
, Rationale: This response acknowledges that the clients is testing limits and that the nurse is f f f f f f f f f f f f f f f
setting them by performing postprandial monitoring to prevent self-induced eyes is. Clients
f f f f f f f f f f f f
with bulimia nervosa need to feel in control of the diet because they feel they lack control over all
f f f f f f f f f f f f f f f f f f
other aspects of their lives. Because their therapeutic relationships with caregivers are less
f f f f f f f f f f f f f f
important than their need to purge, they don't fear betraying the nurse's trust by engaging in the f f f f f f f f f f f f f f f f f
activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or
f f f f f f f f f f f f f f f
challenging response may trigger a power struggle between the nurse and client. f f f f f f f f f f f
A male client admitted to the psychiatric unit for treatment of substance abuse says to the
f f f f f f f f f f f f f f f f
nurse, "It felt so wonderful to get high." Which of the following is the most appropriate
f f f f f f f f f f f f f f f f
response?
A. "If you continue to talk like that, I'm going to stop speaking to you."
f f f f f f f f f f f f f f
B. "You told me you got fired from your past job for missing too may days after taking drugs all
f f f f f f f f f f f f f f f f f f f f
night."
C. "Tell me more about how it felt to get high."
f f f f f f f f f f
D. "Don't you know it's illegal to use drugs?" - B. "You told me you got fired from your past job for
f f f f f f f f f f f f f f f f f f f f f f
missing too many days after taking drugs all night." f f f f f f f f
Rationale: Confronting the client with the consequences of substance abuse helps to break f f f f f f f f f f f f f
through denial. Making threats (option A) isn't an effective way to promote self-disclosure or
f f f f f f f f f f f f f f
establish a rapport with the client. Although the nurse should encourage the client to discuss f f f f f f f f f f f f f f f
feelings, the discussing should focus on how the client felt before, not during, an episode of
f f f f f f f f f f f f f f f f
substance abuse (option C). Encouraging elaboration about his experience while getting high f f f f f f f f f f f f
may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a
f f f f f f f f f f f f f f f f
reminder to this effect (option D) is unlikely to alter behavior. f f f f f f f f f f
For a female client with anorexia nervosa, the nurse is aware that which goal takes the highest
f f f f f f f f f f f f f f f f f
priority?
A. The client will establish adequate daily nutritional intake
f f f f f f f f
B. The client will make a contract with the nurse that sets a target weight
f f f f f f f f f f f f f f
C. The client will identify self-perceptions about body size as unrealistic
f f f f f f f f f f
D. The client will verbalize the possible psychological consequences of self-starvation - A. The
f f f f f f f f f f f f f f
client will establish adequate daily nutritional intake
f f f f f f
Rationale: According to Maslow's Hierarchy of Needs, all humans need to meet basic f f f f f f f f f f f f f
physiological needs first. Because a client with anorexia nervosa eats little or nothing, the f f f f f f f f f f f f f f
nurse must first plan to help the client meet this basic, immediate physiological need. The
f f f f f f f f f f f f f f f
nurse may give lesser priority to goals that address long-term plans (as in option B), self-
f f f f f f f f f f f f f f f
perception (option C), and potential complications (option D). f f f f f f f
When interviewing the parents of an injured child, which of the following is the strongest
f f f f f f f f f f f f f f f
indicator that child abuse may be a problem? f f f f f f f
A. The injury isn't consistent with the history or the child's age
f f f f f f f f f f f
B. The mother and father tell different stories regarding what happened
f f f f f f f f f f
C. The family is poor
f f f f
D. The parents are argumentative and demanding with emergency department personnel - A.
f f f f f f f f f f f f f
The injury isn't consistent with the history or the child's age
f f f f f f f f f f
