Psychiatric Mental Health Nursing NCLEX RN Questions Part 2
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Question 1 of 5.
The client is admitted to the hospital for alcohol detoxification. Which of the following interventions should the nurse use? Select all that apply.
A. Taking vital signs.
B. Monitoring intake and output.
C. Placing the client in restraints as a safety measure.
D. Reinforcing reality if the client is disoriented or hallucinating.
E. Explaining to the client that the symptoms of withdrawal are temporary.
Explanation: Interventions include: Taking vital signs (A) to monitor stability, monitoring intake and output (B) to assess hydration, reinforcing reality (D) to manage disorientation, and explaining withdrawal symptoms are temporary (E) to reduce anxiety. Restraints (C) are not routinely used unless safety is imminently threatened.
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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