Psychiatric Mental Health Nursing NCLEX RN Questions Part 2
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Question 1 of 5.
A client on a stretcher in the emergency department begins to thrash around, slap the sheets and yells, 'Get these bugs off of me.' She is disoriented and has a blood pressure of 189/75 and a pulse of 96. The friend who is with her says, 'She was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any.' The nurse should do the following in which order from first to last?
- A. Obtain an order to place the client in restraints, if needed.
- B. Implement constant observation.
- C. Monitor vital signs every 15 minutes.
- D. Administer haloperidol (Haldol) and lorazepam (Ativan) I.M. as ordered.
- E. Remind the client that she is in the hospital and the nurse is with her.
- F. Chart the client's response to the interventions.
- B. Implement constant observation.
- E. Remind the client that she is in the hospital and the nurse is with her.
- C. Monitor vital signs every 15 minutes.
- D. Administer haloperidol (Haldol) and lorazepam (Ativan) I.M. as ordered.
- A. Obtain an order to place the client in restraints, if needed.
- F. Chart the client's response to the interventions.
Correct arrangement
Explanation: The order is: 1) Constant observation for safety (B). 2) Remind client of hospital setting (E). 3) Monitor vital signs (C). 4) Administer medications (D). 5) Obtain restraint order if needed (A). 6) Chart response (F). Safety and orientation are prioritized, followed by treatment and documentation.
Question 2 of 5.
A client has been taking 30 mg of duloxetine hydrochloride (Cymbalta) twice daily for 2 months because of depression and vague aches and pains. While interacting with the nurse, the client discloses a pattern of drinking a 6-pack of beer daily for the past 10 years to help with sleep. What should the nurse do first?
A. Refer the client to the dual diagnosis program at the clinic.
B. Share the information at the next interdisciplinary treatment conference.
C. Report the client's beer consumption to the physician.
D. Teach the client relaxation exercises to perform before bedtime.
Explanation: Reporting alcohol use to the physician is critical due to potential interactions with Cymbalta, which can increase liver risks or exacerbate depression.
Question 3 of 5.
The nurse is assessing the outcomes of care for a client who has an Axis I diagnosis of major depression. Following the initiation of treatment, arrange the symptoms in chronological order from the one that improves first to the one that improves last.
- A. Self-esteem.
- B. Sleep.
- C. Energy level.
- D. Appetite.
- B. Sleep.
- D. Appetite.
- C. Energy level.
- A. Self-esteem.
Correct arrangement
Explanation: Depression treatment typically improves sleep first, followed by appetite, energy level, and finally self-esteem, which takes longer to recover.
Question 4 of 5.
A 62-year-old female client with severe depression and psychotic symptoms is scheduled for electroconvulsive therapy (ECT) tomorrow morning. The client's daughter asks the nurse, 'How painful will the treatment be for Mom?' The nurse should respond by saying which of the following?
A. Your mother will be given something for pain before the treatment.'
B. The physician will make sure your mother doesn't suffer needlessly.'
C. Your mother will be asleep during the treatment and will not be in pain.'
D. Your mother will be able to talk to us and tell us if she's in pain.'
Explanation: ECT is performed under anesthesia, ensuring the client is unconscious and feels no pain during the procedure.
Question 5 of 5.
The client with recurring depression will be discharged to the community in a few days. Which of the following is the best approach for the nurse to help the family prepare for the client's return home?
A. Discourage visitors while the client is at home.
B. Provide for a schedule of activities outside the home.
C. Involve the client in usual at-home activities.
D. Encourage the client to sleep as much as possible.
Explanation: Involving the client in usual activities promotes normalcy and recovery, balancing rest and engagement.
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