PSYCHIATRIC MENTAL HEALTH NURSING NCLEX
QUESTIONS (50 QUESTIONS) AND ANSWERS
100% CORRECT!!
,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 - 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 - ANSWER C. Identify anxiety-causing situations
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 - ANSWER A. Check on the client frequently at irregular intervals throughout the
night
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.
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 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." - 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.
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?" - 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.
QUESTIONS (50 QUESTIONS) AND ANSWERS
100% CORRECT!!
,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 - 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 - ANSWER C. Identify anxiety-causing situations
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 - ANSWER A. Check on the client frequently at irregular intervals throughout the
night
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.
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 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." - 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.
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?" - 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.
