MENTAL HEALTH Nclex Latest Exam 2024 /Nclex Mental
Health Latest Exam 2024 Questions And 100% Correct
Answers And Rationales/Graded A
Flumazenil (Romazicon) has been ordered for a male client who has
overdosed on oxazepam (Serax). Before administering the medication,
nurse Gina should be prepared for which common adverse effect? -
ANSWER>> Seizures
Seizures are the most common serious adverse effect of using
flumazenil to reverse benzodiazepine overdose
Nurse Tamara is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to: -
ANSWER>> Identify anxiety-causing situations.
Bulimic behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-causing
situations that stimulate the bulimic behavior and then learn new ways
of coping with the anxiety. Bulimia nervosa is a condition that occurs
most commonly in adolescent females, characterized by indulgence in
binge-eating, and inappropriate compensatory behaviors to prevent
weight gain.
A female client who's at high risk for suicide needs close supervision. To
best ensure the client's safety, Nurse Mary should: - ANSWER>> Check
the client frequently at irregular intervals throughout the night
R. 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.
,Which of the following drugs should Nurse Mary prepare to administer
to a client with a toxic acetaminophen (Tylenol) level? - ANSWER>>
Acetylcysteine (Mucomyst)
The antidote for acetaminophen toxicity is acetylcysteine. It enhances
conversion of toxic metabolites to nontoxic metabolites.
A male client is admitted to the substance abuse unit for alcohol
detoxification. Which of the following medications is Nurse Alice most
likely to administer to reduce the symptoms of alcohol withdrawal? -
ANSWER>> D. Chlordiazepoxide (Librium)
Chlordiazepoxide (Librium) and other tranquilizers help reduce the
symptoms of alcohol withdrawal. Chlordiazepoxide is a long-acting
benzodiazepine and is an FDA approved medication for adults with
mild-moderate to severe anxiety disorder, preoperative apprehension
and anxiety, and withdrawal symptoms of acute alcohol use disorder.
Chlordiazepoxide has anti-anxiety, sedative, appetite-stimulating, and
weak analgesic actions. It binds to benzodiazepine receptors at the
GABA-A ligand-gated chloride channel complex and enhances GABA's
inhibitory effects.
During postprandial monitoring, a female client with bulimia nervosa
tells the nurse, "You can sit with me, but you're just wasting your time.
After you had sat with me yesterday, I was still able to purge. Today, my
goal is to do it twice." What is the nurse's best response? - ANSWER>>
Correct ANSWER>>: D. "I know it's important for you to feel in control,
but I'll monitor you for 90 minutes after you eat."
This response acknowledges that the client is testing limits and that the
nurse is setting them by performing postprandial monitoring to prevent
self-induced emesis. 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. Since recovery involves patients having to face their
deepest, most painful, and traumatic thoughts and emotions,
,supporting them as they go through treatment can be emotionally
challenging for nurses. This emotional challenge can be exacerbated
when the patient has also been diagnosed with Obsessive-Compulsive
Disorder (OCD), depression, or substance abuse, as these may require
more intensive one-to-one support.
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? - ANSWER>>
B. "You told me you got fired from your last job for missing too many
days after taking drugs all night."
Confronting the client with the consequences of substance abuse helps
to break through denial. Present reality by spending time with the
client to facilitate reality orientation because your physical presence is
the reality. Be simple, direct, and concise when speaking to the client.
Talk with the client about concrete or familiar things; avoid ideological
or theoretical discussions. The client''s ability to process abstractions or
complexities is impaired.
For a female client with anorexia nervosa, Nurse Jimmy is aware that
which goal takes the highest priority? - ANSWER>> Correct ANSWER>>:
A. The client will establish adequate daily nutritional intake.
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. Treatment for anorexia
nervosa is centered on nutrition rehabilitation and psychotherapy.
Refeeding syndrome can occur following prolonged starvation. As the
body utilizes glucose to produce molecules of adenosine triphosphate
(ATP), it depletes the remaining stores of phosphorus. Also, glucose
entry into cells is mediated by insulin and occurs rapidly following long
periods without food. Both cause electrolyte abnormalities such as
hypophosphatemia and hypokalemia, triggering cardiac and respiratory
, compromise. Patients should be followed carefully for signs of
refeeding syndrome and electrolytes closely monitored.
When interviewing the parents of an injured child, which of the
following is the strongest indicator that child abuse may be a problem?
- ANSWER>> The injury isn't consistent with the history or the child's
age.
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. Physical indicators may include injuries to a child that are
severe, occur in a pattern or occur frequently. These injuries range
from bruises to broken bones to burns or unusual lacerations. The child
may present for care unrelated to the abuse, and the abuse may be
found incidentally.
For a female client with anorexia nervosa, nurse Rose plans to include
the parents in therapy sessions along with the client. What fact should
the nurse remember to be typical of parents of clients with anorexia
nervosa? - ANSWER>> They tend to overprotect their children.
Clients with anorexia nervosa typically come from a family with parents
who are controlling and overprotective. These clients use eating to gain
control of an aspect of their lives. Similarly, issues like anxiety,
depression, and addiction can also run in families, and have also been
found to increase the chances that a person will develop an eating
disorder. Many people with anorexia report that, as children, they
always followed the rules and felt there was one "right way" to do
things.
In the emergency department, a client with facial lacerations states
that her husband beat her with a shoe. After the health care team
repairs her lacerations, she waits to be seen by the crisis intake nurse,
who will evaluate the continued threat of violence. Suddenly the
Health Latest Exam 2024 Questions And 100% Correct
Answers And Rationales/Graded A
Flumazenil (Romazicon) has been ordered for a male client who has
overdosed on oxazepam (Serax). Before administering the medication,
nurse Gina should be prepared for which common adverse effect? -
ANSWER>> Seizures
Seizures are the most common serious adverse effect of using
flumazenil to reverse benzodiazepine overdose
Nurse Tamara is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to: -
ANSWER>> Identify anxiety-causing situations.
Bulimic behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-causing
situations that stimulate the bulimic behavior and then learn new ways
of coping with the anxiety. Bulimia nervosa is a condition that occurs
most commonly in adolescent females, characterized by indulgence in
binge-eating, and inappropriate compensatory behaviors to prevent
weight gain.
A female client who's at high risk for suicide needs close supervision. To
best ensure the client's safety, Nurse Mary should: - ANSWER>> Check
the client frequently at irregular intervals throughout the night
R. 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.
,Which of the following drugs should Nurse Mary prepare to administer
to a client with a toxic acetaminophen (Tylenol) level? - ANSWER>>
Acetylcysteine (Mucomyst)
The antidote for acetaminophen toxicity is acetylcysteine. It enhances
conversion of toxic metabolites to nontoxic metabolites.
A male client is admitted to the substance abuse unit for alcohol
detoxification. Which of the following medications is Nurse Alice most
likely to administer to reduce the symptoms of alcohol withdrawal? -
ANSWER>> D. Chlordiazepoxide (Librium)
Chlordiazepoxide (Librium) and other tranquilizers help reduce the
symptoms of alcohol withdrawal. Chlordiazepoxide is a long-acting
benzodiazepine and is an FDA approved medication for adults with
mild-moderate to severe anxiety disorder, preoperative apprehension
and anxiety, and withdrawal symptoms of acute alcohol use disorder.
Chlordiazepoxide has anti-anxiety, sedative, appetite-stimulating, and
weak analgesic actions. It binds to benzodiazepine receptors at the
GABA-A ligand-gated chloride channel complex and enhances GABA's
inhibitory effects.
During postprandial monitoring, a female client with bulimia nervosa
tells the nurse, "You can sit with me, but you're just wasting your time.
After you had sat with me yesterday, I was still able to purge. Today, my
goal is to do it twice." What is the nurse's best response? - ANSWER>>
Correct ANSWER>>: D. "I know it's important for you to feel in control,
but I'll monitor you for 90 minutes after you eat."
This response acknowledges that the client is testing limits and that the
nurse is setting them by performing postprandial monitoring to prevent
self-induced emesis. 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. Since recovery involves patients having to face their
deepest, most painful, and traumatic thoughts and emotions,
,supporting them as they go through treatment can be emotionally
challenging for nurses. This emotional challenge can be exacerbated
when the patient has also been diagnosed with Obsessive-Compulsive
Disorder (OCD), depression, or substance abuse, as these may require
more intensive one-to-one support.
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? - ANSWER>>
B. "You told me you got fired from your last job for missing too many
days after taking drugs all night."
Confronting the client with the consequences of substance abuse helps
to break through denial. Present reality by spending time with the
client to facilitate reality orientation because your physical presence is
the reality. Be simple, direct, and concise when speaking to the client.
Talk with the client about concrete or familiar things; avoid ideological
or theoretical discussions. The client''s ability to process abstractions or
complexities is impaired.
For a female client with anorexia nervosa, Nurse Jimmy is aware that
which goal takes the highest priority? - ANSWER>> Correct ANSWER>>:
A. The client will establish adequate daily nutritional intake.
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. Treatment for anorexia
nervosa is centered on nutrition rehabilitation and psychotherapy.
Refeeding syndrome can occur following prolonged starvation. As the
body utilizes glucose to produce molecules of adenosine triphosphate
(ATP), it depletes the remaining stores of phosphorus. Also, glucose
entry into cells is mediated by insulin and occurs rapidly following long
periods without food. Both cause electrolyte abnormalities such as
hypophosphatemia and hypokalemia, triggering cardiac and respiratory
, compromise. Patients should be followed carefully for signs of
refeeding syndrome and electrolytes closely monitored.
When interviewing the parents of an injured child, which of the
following is the strongest indicator that child abuse may be a problem?
- ANSWER>> The injury isn't consistent with the history or the child's
age.
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. Physical indicators may include injuries to a child that are
severe, occur in a pattern or occur frequently. These injuries range
from bruises to broken bones to burns or unusual lacerations. The child
may present for care unrelated to the abuse, and the abuse may be
found incidentally.
For a female client with anorexia nervosa, nurse Rose plans to include
the parents in therapy sessions along with the client. What fact should
the nurse remember to be typical of parents of clients with anorexia
nervosa? - ANSWER>> They tend to overprotect their children.
Clients with anorexia nervosa typically come from a family with parents
who are controlling and overprotective. These clients use eating to gain
control of an aspect of their lives. Similarly, issues like anxiety,
depression, and addiction can also run in families, and have also been
found to increase the chances that a person will develop an eating
disorder. Many people with anorexia report that, as children, they
always followed the rules and felt there was one "right way" to do
things.
In the emergency department, a client with facial lacerations states
that her husband beat her with a shoe. After the health care team
repairs her lacerations, she waits to be seen by the crisis intake nurse,
who will evaluate the continued threat of violence. Suddenly the
