Psychiatric Mental Health Nursing NCLEX Questions (50 Questions)

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting the neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hyper vigilance and talk of past violent acts

A. A rigid posture, restlessness, and glaring Rationale: Behavior clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentative ness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance.

The nurse is aware that which outcome criteria would be appropriate for a child diagnosed with oppositional defiance disorder? A. Accept the responsibility for own behaviors B. Be able to verbalize own needs and assert rights C. Set firm and consistent limits with the client D. Allow the client to establish his own limits and boundaries

A. Accept the responsibility for own behaviors Rationale: 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 in incorrect as the oppositional child usually focuses on his own needs.

A male client is being treated for alcoholism. After a family meetings, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join with organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A. Al-Anon Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder

A. Antisocial personality disorder Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.

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.

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neuribehavioral deficits D. Panic disorder

A. Coronary artery spasm Rationale: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not panic disorder.

The nurse is aware that which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120-140 beats/minute B. Heart rate of 50-60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg

A. Heart rate of 120-140 beats/minute Rationale: Tachycardia, a heart rate of 120-140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labeled throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for 1 hour afterward B. Letting the client ears with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired

A. Providing one-on-one supervision during meals and for 1 hour afterward Rationale: Because the client with anorexia nervosa, may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option C would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected.

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.

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

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

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? A. They tend to overprotects their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children

A. They tend to overprotect their children Rationale: 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 characteristic described in options B, C, and D isn't typical of parents of children with anorexia.

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse? A. "Why didn't you get someone else to drive?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."

B. "Tell me how you feel about the accident." Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that client isn't capable of making decision, thus fostering dependency.

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: 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.

The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

B. Aftershave lotion Rationale: Disulfiram may be given to client 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 product 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.

The nurse is assigned to care for a suicidal client. Which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergy person to discuss the moral implications of suicide

B. Exploring the nurse's own feelings about suicide Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal clients; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicidal 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 clergy person may increase the client's trust or alleviate guilt; however, it isn't the highest priority.

A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. Manipulate her husband B. Gain control of one part of her life C. Commit suicide D. Live up to her mother's expectations

B. Gain control of one part of her life Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control. This eating disorder doesn't represent an attempt to manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families that emphasizes achievement). The client isn't attempting to commit suicide through starvation; rather, by refusing to eat, she is expressing feelings or despair, worthlessness,s and hopelessness.

The nurse is aware that which client is at highest risk for suicide? A. One who appears depressed, frequently thinks of dying, and gives away all personal possessions B. One who plans a violence death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die

B. One who plans a violent death and has the means readily available Rationale: The client at highest risks for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempt suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that this client is contemplating suicide and wishes to be helped.

The nurse is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationships (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization

B. Readiness to leave the perpetrator and knowledge or resources Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of 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 person's seeking or causing abusive relationships.

A 25-year-old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strengths

B. The client will work with the nurse to remain safe Rationale: The priority goal in alcohol withdrawal is maintaining the client' safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensure the client's safety is the nurse's top priority.

When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Clients psychosocial needs D. Client's medical needs

B. The client's safety needs Rationale: 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 are met, the client's physical, psychosocial, and medical needs can be met.

Kellan, a high school student, is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use B. The student accepts a referral to a substance abuse counselor C. The student agrees to inform his parents of the problem D. The student reports increased comfort with making choices

B. The student accepts a referral to a substance abuse counselor Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup D. A below-normal serum potassium level

B. Thiamine deficiency Rationale: 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 dietary 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.

A male client has approached the nurse asking for advice on how to derail with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy

B. Total abstinence Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies than can support the client in his efforts to abstain.

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'nm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."

C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror. Proffering fast food over health food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in this client with anorexia nervosa.

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. Begin after 7 days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next 1-2 days D. Begin within 2-7 days

C. Begin anytime within the next 1-2 days Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1-2 days later. Delirium tremens may occur 2-4 days - even up to 7 days - after the last drink.

The nurse is aware that which of the following medical conditions is commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A

C. Diabetes mellitus Rationale: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A.

The nurse is aware that drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil)

C. Haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome.

Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband: A. Only has moderate impulse control B. Denies feelings of jealousy or possessiveness C. Has learned violence as an acceptable behavior D. Feels secure in his relationship with his wife

C. Has learned violence as an acceptable behavior Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.

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.

The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count

C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Rationale: 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.

A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)

C. Lorazepam (Ativan) Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an anti manic agent; these drugs aren't used to manage alcohol withdrawal syndrome.

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to: A. Severely restrict the client's physical activities B. Weigh the client daily, after the evening meal C. Monitor vital signs, serum electrolytes levels, and acid-base balance D. Instruct the client to keep an accurate record of food and fluid intake

C. Monitor vital signs, serum electrolyte levels, and acid-base balance Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte levels, and acid-base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately.

A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal cheats pain. The electrocardiography (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, the nurse expects the physician to prescribe: A. Lidocaine (Xylocaine) B. Procainamide (Pronestyl) C. Nitroglycerin (Nitro-Bid IV) D. Epinephrine

C. Nitroglycerin (Nitro-Bid IV) Rationale: The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or a systole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potential even its adrenergic effects.

Clonidine (Catapres) can used to treat conditions other than hypertension. The nurse is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

C. Opiate withdrawal Rationale: Clonidine is used as adjective therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.

A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best nursing intervention at this time is: A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medications as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes

C. Providing a quiet environment and administering medications as needed and prescribed Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptom without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restrains may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt B. Situational low self-esteem related to feelings of loss of control C. Risk for violence: Self-directed related to impulsive mutilating acts D. Risk for violence: Directed toward other related to verbal threats

C. Risk for violence: Self-directed related to impulsive mutilating acts Rationale: The predominant behavior characteristic of the client with borderline personal out disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety

C. Set up a strict eating plan for the client Rationale: 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 should be limited and supervised.

A parents brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably thoughout the examination B. The child pulls away from contact with the physician C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse

C. The child doesn't cry when the shoulder is examined Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by the healthcare 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.

Client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Rationale: According the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge or having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), increased time and money spent on the substance (option B), inability to fulfill role obligations (option C), and typical withdrawal symptoms.

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 is found, sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? A. Enter the room quietly and move beside her to assess her injuries B. Call for staff back-up before entering the room and restraining her C. Move as much glass away from her and possible and sit next to her quietly D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her

D. Approach her slowly while speaking in a calm, voice, calling her name, and telling her that the nurse is here to help her Rationale: Ensuring the safety of the client and 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 here 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 or 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.

A male client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses container occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101 F (38.3 C), and pruritis C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

D. Diaphoresis, tremors, and nervousness Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbances, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia - not - bradycardia - is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101 F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.

When monitoring a female client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. Norepinephrine (Levophed) and lidocaine (Xylocaine) B. Nifedipine (Procardia) and lidocaine (Xylocaine) C. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc) D. Nifedipine (Procardia) and esmolol (Brevibloc)

D. Nifedipine (Procardia) and esmolol (Brevibloc) Rationale: This client requires a vasodilator, such as nifedipine to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an anti arrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension.

A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings B. Focus discussions on food and weight C. Avoid discussing unrealistic cultural standards regarding weight D. Provide objective data and feedback regarding the client's weight and attractiveness

D. Provide objective data and feedback regarding the client's weight and attractiveness Rationale: 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 feelings wouldn't help her identify, accept, and work through them. Focusing discussions on food and weight would 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.

A female client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals that the client is 5'8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should the nurse include in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, schedule during each shift D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy

D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy Rationale: 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.

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.

Eighteen hours after undoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6 F (38.7 C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mmHg. The client exhibits gross hand tremors and is screening for someone to kill the bugs in the bed. The nurse should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis D. Pneumonia

The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complication, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.

In the emergency department, a client with a 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 client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry

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 s 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 saturation 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.