Psychiatric Mental Health Nursing NCLEX
Questions (50 Questions) with verified solutions
2024\2025 A+ Grade
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
- correct 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
- correct 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
- correct 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.
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)
- correct answer 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)
- correct answer 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."
- 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."
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?"
- correct 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) with verified solutions
2024\2025 A+ Grade
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
- correct 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
- correct 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
- correct 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.
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)
- correct answer 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)
- correct answer 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."
- 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."
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?"
- correct 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.
