A client on a stretcher in the emergency department begins to thrash a

Mental Health RN NCLEX Questions

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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.

Correct arrangement

B. Implement constant observation.
E. Remind the client that she is in the hospital and the nurse is with her.
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.

Explanation: First implement observation, orient the client, monitor vital signs, administer medications, consider restraints if needed, and chart responses.

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.