PSYCHIATRIC MENTAL HEALTH NURSING NCLEX QUESTIONS WITH
CORRECT ANSWERS #3
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.
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 -
correct answer A. 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 - correct answer A. 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.
For a female client with anorexia nervosa, the nurse 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?
CORRECT ANSWERS #3
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.
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 -
correct answer A. 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 - correct answer A. 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.
For a female client with anorexia nervosa, the nurse 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?
