Psychiatric Mental Health Nursing NCLEX RN Questions Part 1 Answers and Rationale

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1.    Answer A. Seizures are the most common serious 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 include shivering, anxiety, and chest pain.
2.    Answer C. 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. 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.
3.    Answer A. 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 or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn’t disregard it (option D)
4.    Answer D. The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.
5.    Answer D. 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 administered to treat seizures if they occur during withdrawal.
6.    Answer D. 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. 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.
7.    Answer B. 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 discussion 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.
8.    Answer A. 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 (as in option C), and potential complications (as in option D).
9.    Answer A. 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 when 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.
10.    Answer A. 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. The characteristics described in options B, C, and D isn’t typical of parents of children with anorexia.
11.    Answer B. The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn’t attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn’t take precedence over safeguarding the client and staff.
12.    Answer C. Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.
13.    Answer B. The nurse’s values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client’s home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn’t a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn’t a priority. Referring the client to a clergyperson may increase the client’s trust or alleviate guilt; however, it isn’t the highest priority.
14.    Answer D. By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client’s perceptions and feeling wouldn’t help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn’t help the client establish more realistic weight goals.
15.    Answer B. Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don’t contain alcohol and don’t need to be avoided by the client.
16.    Answer C. Establishing a consistent eating plan and monitoring the client’s weight are important for this disorder. The family should be included in the client’s care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.
17.    Answer B. Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person’s seeking or causing abusive relationships.
18.    Answer B. Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client’s symptoms.
19.    Answer C. A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers.

20.    Answer B. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client’s physical, psychosocial, and medical needs can be met.
21.    Answer A. Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren’t outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.
22.    Answer D. Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn’t be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client’s response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn’t attempt to sit next to the client or examine injuries without first announcing the nurse’s presence and assessing the dangers of the situation.
23.    Answer D. A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client’s health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.
24.    Answer B. The client’s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn’t cause this client’s signs and symptoms and typically would occur later in the postoperative course
25.    Answer C. Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

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