Psychiatric NCLEX RN Questions
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Question 1 of 5.
Extract:The following scenario applies to the next 1 items The nurse is caring for a client in the mental health unit experiencing psychosis Item 1 of 1 Nurses' Notes 1300 – Client was banging their food tray and shouting at other clients. De-escalated the situation by escorting the client back to their room. Once back to their room, the client kept shouting ‘they are after me!' at the roommate. The client stopped the shouting but resumed several minutes later. The client refused the scheduled by-mouth (PO) olanzapine, stating, ‘they don't want me to take that.' Medications Olanzapine 10 mg PO Daily Medical History • Schizophrenia • Vitamin D deficiency • Hyperlipidemia
Select two (2) actions the nurse should take
A. Provide therapeutic touch
B. Limit interaction with the client
C. Place the client in seclusion
D. Ask if the client hears any voices
E. Crush the olanzapine in the client's food
F. Reassign the client to a private room
Explanation: Asking about hallucinations assesses the client's psychosis, and a private room reduces stimuli and conflict, promoting safety and de-escalation.
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 2–4 week onset of antidepressants sets realistic expectations and encourages adherence.
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