Psychiatric Mental Health Nursing
NCLEX Questions (50 Questions)
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 - ANSA. 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 - ANSC. 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 -
ANSA. 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.
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) - ANSD. 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 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) - ANSD. 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 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." - ANSD. "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?" - ANSB. "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.
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 - ANSA.
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?
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 -
ANSA. 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.
NCLEX Questions (50 Questions)
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 - ANSA. 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 - ANSC. 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 -
ANSA. 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.
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) - ANSD. 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 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) - ANSD. 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 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." - ANSD. "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?" - ANSB. "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.
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 - ANSA.
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?
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 -
ANSA. 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.
