PSYCHIATRIC MENTAL HEALTH NURSING NCLEX QUESTIONS (50
QUESTIONS) ANSWERED | RATED A+
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 - 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 - 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 - 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.
,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) - 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 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) - 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 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." - 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?" - B. "You told me you got fired from your
past job for missing too many days after taking drugs all night."
Rationale: bConfronting bthe bclient bwith bthe bconsequences bof bsubstance babuse bhelps bto
bbreak bthrough bdenial. bMaking bthreats b(option bA) bisn't ban beffective bway bto bpromote bself-
disclosure bor bestablish ba brapport bwith bthe bclient. bAlthough bthe bnurse bshould bencourage
bthe bclient bto bdiscuss bfeelings, bthe bdiscussing bshould bfocus bon bhow bthe bclient bfelt
bbefore, bnot bduring, ban bepisode bof bsubstance babuse b(option bC). bEncouraging
belaboration babout bhis bexperience bwhile bgetting bhigh bmay breinforce bthe babusive
bbehavior. bThe bclient bundoubtedly bis baware bthat bdrug buse bis billegal; ba breminder bto bthis
beffect b(option bD) bis bunlikely bto balter bbehavior.
For ba bfemale bclient bwith banorexia bnervosa, bthe bnurse bis baware bthat bwhich bgoal btakes
bthe bhighest bpriority?
A. bThe bclient bwill bestablish badequate bdaily bnutritional bintake
B. bThe bclient bwill bmake ba bcontract bwith bthe bnurse bthat bsets ba btarget bweight
C. bThe bclient bwill bidentify bself-perceptions babout bbody bsize bas bunrealistic
D. bThe bclient bwill bverbalize bthe bpossible bpsychological bconsequences bof bself-starvation
b- b bA. bThe bclient bwill bestablish badequate bdaily bnutritional bintake
Rationale: bAccording bto bMaslow's bHierarchy bof bNeeds, ball bhumans bneed bto bmeet bbasic
bphysiological bneeds bfirst. bBecause ba bclient bwith banorexia bnervosa beats blittle bor bnothing,
bthe bnurse bmust bfirst bplan bto bhelp bthe bclient bmeet bthis bbasic, bimmediate bphysiological
bneed. bThe bnurse bmay bgive blesser bpriority bto bgoals bthat baddress blong-term bplans b(as bin
boption bB), bself-perception b(option bC), band bpotential bcomplications b(option bD).
When binterviewing bthe bparents bof ban binjured bchild, bwhich bof bthe bfollowing bis bthe
bstrongest bindicator bthat bchild babuse bmay bbe ba bproblem?
A. bThe binjury bisn't bconsistent bwith bthe bhistory bor bthe bchild's bage
B. bThe bmother band bfather btell bdifferent bstories bregarding bwhat bhappened
C. bThe bfamily bis bpoor
D. bThe bparents bare bargumentative band bdemanding bwith bemergency bdepartment
bpersonnel b- b bA. bThe binjury bisn't bconsistent bwith bthe bhistory bor bthe bchild's bage
Rationale: bWhen bthe bchild's binjuries bare binconsistent bwith bthe bhistory bgiven bor
bimpossible bbecause bof bthe bchild's bage band bdevelopmental bstage, bthe bemergency
bdepartment bnurse bshould bbe bsuspicious bthat bchild babuse bis boccurring. bThe bparents
bmay btell bdifferent bstories bbecause btheir bperception bmay bbe bdifferent bregarding bwhat
bhappened. bIf bthey bchange btheir bstory bwith bdifferent bhealth bcare bworkers bask bthe bsame
bquestion, bthis bis ba bclue bthat bchild babuse bmay bbe ba bproblem. bChild babuse boccurs bin ball
bsocioeconomic bgroups. bParents bmay bargue band bbe bdemanding bbecause bof bthe bstress
bof bhaving ban binjured bchild.
QUESTIONS) ANSWERED | RATED A+
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 - 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 - 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 - 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.
,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) - 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 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) - 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 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." - 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?" - B. "You told me you got fired from your
past job for missing too many days after taking drugs all night."
Rationale: bConfronting bthe bclient bwith bthe bconsequences bof bsubstance babuse bhelps bto
bbreak bthrough bdenial. bMaking bthreats b(option bA) bisn't ban beffective bway bto bpromote bself-
disclosure bor bestablish ba brapport bwith bthe bclient. bAlthough bthe bnurse bshould bencourage
bthe bclient bto bdiscuss bfeelings, bthe bdiscussing bshould bfocus bon bhow bthe bclient bfelt
bbefore, bnot bduring, ban bepisode bof bsubstance babuse b(option bC). bEncouraging
belaboration babout bhis bexperience bwhile bgetting bhigh bmay breinforce bthe babusive
bbehavior. bThe bclient bundoubtedly bis baware bthat bdrug buse bis billegal; ba breminder bto bthis
beffect b(option bD) bis bunlikely bto balter bbehavior.
For ba bfemale bclient bwith banorexia bnervosa, bthe bnurse bis baware bthat bwhich bgoal btakes
bthe bhighest bpriority?
A. bThe bclient bwill bestablish badequate bdaily bnutritional bintake
B. bThe bclient bwill bmake ba bcontract bwith bthe bnurse bthat bsets ba btarget bweight
C. bThe bclient bwill bidentify bself-perceptions babout bbody bsize bas bunrealistic
D. bThe bclient bwill bverbalize bthe bpossible bpsychological bconsequences bof bself-starvation
b- b bA. bThe bclient bwill bestablish badequate bdaily bnutritional bintake
Rationale: bAccording bto bMaslow's bHierarchy bof bNeeds, ball bhumans bneed bto bmeet bbasic
bphysiological bneeds bfirst. bBecause ba bclient bwith banorexia bnervosa beats blittle bor bnothing,
bthe bnurse bmust bfirst bplan bto bhelp bthe bclient bmeet bthis bbasic, bimmediate bphysiological
bneed. bThe bnurse bmay bgive blesser bpriority bto bgoals bthat baddress blong-term bplans b(as bin
boption bB), bself-perception b(option bC), band bpotential bcomplications b(option bD).
When binterviewing bthe bparents bof ban binjured bchild, bwhich bof bthe bfollowing bis bthe
bstrongest bindicator bthat bchild babuse bmay bbe ba bproblem?
A. bThe binjury bisn't bconsistent bwith bthe bhistory bor bthe bchild's bage
B. bThe bmother band bfather btell bdifferent bstories bregarding bwhat bhappened
C. bThe bfamily bis bpoor
D. bThe bparents bare bargumentative band bdemanding bwith bemergency bdepartment
bpersonnel b- b bA. bThe binjury bisn't bconsistent bwith bthe bhistory bor bthe bchild's bage
Rationale: bWhen bthe bchild's binjuries bare binconsistent bwith bthe bhistory bgiven bor
bimpossible bbecause bof bthe bchild's bage band bdevelopmental bstage, bthe bemergency
bdepartment bnurse bshould bbe bsuspicious bthat bchild babuse bis boccurring. bThe bparents
bmay btell bdifferent bstories bbecause btheir bperception bmay bbe bdifferent bregarding bwhat
bhappened. bIf bthey bchange btheir bstory bwith bdifferent bhealth bcare bworkers bask bthe bsame
bquestion, bthis bis ba bclue bthat bchild babuse bmay bbe ba bproblem. bChild babuse boccurs bin ball
bsocioeconomic bgroups. bParents bmay bargue band bbe bdemanding bbecause bof bthe bstress
bof bhaving ban binjured bchild.
