A nurse is caring for a client admitted to the hospital for heroin det

Psychiatric NCLEX RN Questions

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Question 1 of 5.

A nurse is caring for a client admitted to the hospital for heroin detoxification. Which nursing intervention is most appropriate for addressing the client's withdrawal symptoms?

A. Administering antipsychotic medications

B. Providing a warm, quiet environment

C. Encouraging increased fluid intake

D. Restricting caffeine intake

Explanation: A warm, quiet environment (B) reduces stimulation and promotes comfort during heroin withdrawal, which includes symptoms like anxiety and irritability. Antipsychotics (A) are not indicated for withdrawal. Fluid intake (C) and caffeine restriction (D) are secondary and less specific to withdrawal symptom management.

Question 2 of 5.

The client is taking 50 mg of lamotrigine (Lamictal) daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do?

A. Report the rash to the physician.

B. Explain that the rash is a temporary adverse effect.

C. Give the client an ice pack for his arm.

D. Question the client about recent sun exposure.

Explanation: A rash with Lamictal may indicate a serious reaction like Stevens-Johnson syndrome, requiring immediate physician notification.

Question 3 of 5.

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate?

A. I'll sit here with you for 15 minutes.'

B. I'll come back a little bit later to talk.'

C. I'll find someone else for you to talk with.'

D. I'll get you something to read.'

Explanation: Sitting quietly with the client provides presence and support, respecting their current inability to engage.

Question 4 of 5.

During an interaction with the nurse, a client states, 'My husband has supported me every time I've been hospitalized for depression. He'll leave me this time. I'm an awful wife and mother. I'm no good. Nothing I do is right.' Based on this information, which of the following nursing diagnoses should the nurse identify when developing the client's plan of care?

A. Impaired social interaction related to unsatisfactory relationships as evidenced by withdrawal.

B. Chronic low self-esteem related to lack of self-worth as evidenced by negative self-statements.

C. Risk for self-directed violence related to feelings of guilt as evidenced by statements of suicidal ideation.

D. Ineffective coping related to hospitalizations as evidenced by impaired judgment.

Explanation: The client's negative self-statements directly indicate chronic low self-esteem, a priority nursing diagnosis.

Question 5 of 5.

The client who has been taking venlafaxine (Effexor) 25 mg P.O. three times a day for the past 2 days states, 'This medicine isn't doing me any good. I'm still so depressed.' Which of the following responses by the nurse is most appropriate?

A. I'm sure the medicine will help you soon.'

B. It usually takes about 2 to 4 weeks for the medicine to work.'

C. Maybe the doctor will change your medicine.'

D. Tell me more about how you're feeling.'

Explanation: Explaining the 2â€“4 week onset of antidepressants sets realistic expectations and encourages adherence.