A client known to have alcohol dependence is admitted to the emergency

Mental Health RN NCLEX Questions

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Question 1 of 5.

A client known to have alcohol dependence is admitted to the emergency department with a temperature of 99Â°F, a pulse of 110, respirations of 26, and blood pressure of 150/98. The blood alcohol level is 0.25%, three times the legal limit. Now the client is becoming belligerent and uncooperative. In which order from first to last should the following nursing and medical orders be implemented?

A. Administer lorazepam (Ativan) 2 mg I.M.
B. Draw blood for a magnesium level.
C. Take vital signs every 15 minutes.
D. Place client in a quiet room with dimmed lights.

Correct arrangement

D. Place client in a quiet room with dimmed lights.
A. Administer lorazepam (Ativan) 2 mg I.M.
C. Take vital signs every 15 minutes.
B. Draw blood for a magnesium level.

Explanation: The order is: 1) Place the client in a quiet room to reduce stimulation and agitation (D). 2) Administer lorazepam to manage belligerence and withdrawal symptoms (A). 3) Take vital signs every 15 minutes to monitor stability (C). 4) Draw blood for magnesium level to assess electrolyte status (B). This prioritizes de-escalation, symptom management, monitoring, and diagnostics.

Question 2 of 5.

After a period of unsuccessful treatment with Elavil (amitriptyline), a woman diagnosed with depression is switched to Parnate (tranylcypromine). Which statement by the client indicates the client understands the side effects of Parnate?

A. I must do increase my intake of sodium.'

B. I must refrain from strenuous exercise.'

C. I must refrain from eating aged cheese or yeast products.'

D. I should decrease my intake of foods containing sugar.'

Explanation: Parnate is a monoamine oxidase inhibitor (MAOI), and clients must avoid tyramine-rich foods like aged cheese and yeast products to prevent hypertensive crisis.

Question 3 of 5.

A nurse is conducting a psychoeducational group for family members of clients hospitalized with depression. Which family member's statement indicates a need for additional teaching?

A. My husband will slowly feel better as his medicine takes effect over the next 2 to 4 weeks.'

B. My wife will need to take her antidepressant medicine and go to group to stay well.'

C. My son will only need to attend outpatient appointments when he starts to feel depressed again.'

D. My mother might need help with grocery shopping, cooking, and cleaning for a while.'

Explanation: Depression requires ongoing outpatient care to prevent relapse, not just when symptoms reappear.

Question 4 of 5.

A client is receiving paroxetine (Paxil) 20 mg every morning. After taking the first three doses, the client tells the nurse that the medication upsets his stomach. Which of the following instructions should the nurse give to the client?

A. Take the medication an hour before breakfast.'

B. Take the medication with some food.'

C. Take the medication at bedtime.'

D. Take the medication with 4 oz of orange juice.'

Explanation: Taking paroxetine with food can reduce gastrointestinal side effects like nausea.

Question 5 of 5.

A client who is depressed states, 'I'm an awful person. Everything about me is bad. I can't do anything right.' Which of the following responses by the nurse is most therapeutic?

A. Everybody around here likes you.'

B. I can see many good qualities in you.'

C. Let's discuss what you've done correctly.'

D. You were able to bathe today.'

Explanation: Discussing specific accomplishments challenges negative self-perceptions and promotes cognitive restructuring.