NCLEX RN Questions on Psychiatric Nursing
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Question 1 of 5.
Extract:The nurse in the emergency department (ED) is caring for a 19-year-male client. Nurses' Notes 0210: Client brought to the ED via ambulance. The client was at a party and was ingesting an unknown substance. The client became paranoid, lashing out at other individuals, reported feeling 'very hot.' and subsequently collapsed on the ground. 0216: On assessment, the client was hyper-alert, vigilant, and paranoid. "I know you are out to get me!" Not oriented to situation. Pupils were 5 mm. Electrocardiogram shows sinus tachycardia with a rate of 126. Peripheral pulses 1+. Lung sounds were clear bilaterally. Abdomen was taut, normoactive bowel sounds in all quadrants. Vital signs: T 103° F (39.7° C), P 126, RR 22, BP 156/96, pulse oximetry reading 98% on room air. 0220: Physician notified for orders. 0239: Orders received. 22-gauge intravenous access was obtained in the left forearm. 0300: Vital signs reassessed: T 103° F (39.7° C), P 129, RR 24, BP 160/96, pulse oximetry reading 97% on room air. 0315: Called to the room by the nursing assistant. The client struck the nursing assistant with his closed fist. The client discontinued his IV access.
Complete the following sentence by using the lists of options. The nurse should first address this client's --------------as evidenced by the client's------------------------
- A. Temperature
- B. behavior
- C. blood pressure
- D. fluid status
- E. physical violence
- F. vital signs
- B. behavior
- E. physical violence
Correct arrangement
Explanation: The nurse must immediately address this client's behavior because of its scalation that has led to the client assaulting the nursing assistant. It is the impression from the case study that this client is under the influence of a sympathomimetic, such as methamphetamine. Methamphetamine can cause a client to develop hyperarousal, leading to hypertension, tachycardia, and psychotic symptoms. Clients with acute methamphetamine intoxication may, without provocation, abruptly develop severe agitation and manifest extreme violence.Uncontrolled agitation results in hyperthermia, acidosis, rhabdomyolysis, and sudden cardiovascular collapse. Control of agitation and chemical sedation is a clinical priority.The nurse should immediately restrain the client and then notify the physician. In this extreme situation where the client has used physical violence, the nurse has the ability to restrain the client and then notify the physician. Once the client is restrained, the nurse should restart the vascular access device and administer prescribed diazepam to ameliorate the client's aggression further. The benzodiazepine (diazepam) will also lower his high pulse and blood pressure.
Question 2 of 5.
The nurse is conducting an intake interview with an Asian American female who reports sadness, physical and mental fatigue, anxiety, and sleep disturbance. Prior to the client's time with the physician, it is important for the nurse to obtain information about the client's use of which of the following? Select all that apply.
A. Tea.
B. Herbal medicine.
C. Breathing exercise.
D. Massage.
E. Folk healer.
Explanation: Herbal medicine, breathing exercises, massage, and folk healers may impact treatment or interact with medications, requiring assessment.
Question 3 of 5.
A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse is most therapeutic?
A. Wait for the client to begin the conversation.
B. Initiate contact with the client frequently.
C. Sit outside the client's room.
D. Question the client until he responds.
Explanation: Frequent initiation of contact shows care and encourages engagement without overwhelming the client.
Question 4 of 5.
During a group session, a client who is depressed tells the group that he lost his job. Which of the following responses by the nurse is best?
A. It must have been very upsetting for you.'
B. Would you tell us about your job.'
C. You'll find another job when you're better.'
D. You were probably too depressed to work.'
Explanation: Acknowledging the emotional impact validates the client's feelings and fosters therapeutic rapport.
Question 5 of 5.
A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his 'bowels have turned to jelly,' which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the physician. Which of the following should the nurse identify as a criterion for the client to be legally committable?
A. Evidence of psychosis.
B. Being gravely disabled.
C. Risk of harm to self or others.
D. Diagnosis of mental illness.
Explanation: Risk of harm to self or others is a primary criterion for involuntary commitment to ensure safety.
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