Psychiatric Mental Health Nursing Success NCLEX questions

Psychiatric Mental Health Nursing Success NCLEX questions Leave the first rating Students also studied Terms in this set (22) Science MedicineNursing Save RN Learning System Fundamentals ...40 terms gaycriminalPreview ATI Fundamentals 2 Quiz 41 terms michiibibiPreview Anxiety Disorders Practice Question...24 terms jennibugarinPreview OB NC 60 terms sma

• The client will remain safe throughout the duration of

the panic attack.

Rationale: 1. Remaining safe throughout the duration

of the panic attack is the priority outcome for the client.When a client experiences a panic attack, which correctly written outcome takes priority?

• The client will remain safe throughout the duration of the panic attack.
• The client will verbalize an anxiety level of less than 2/10.
• The client will use learned coping mechanisms to decrease anxiety.
• The client will verbalize the positive effects of exercise by day 2.
• A client pacing the halls and stating that his anxiety is

an 8/10.

Rationale: A client pacing the halls and experiencing an

increase in anxiety commands immedi- ate assessment. If the nurse does not take action on this assessment, there is a potential for client injury to self or other The nurse has received the evening report. Which client would the nurse need to assess first?

• A newly admitted client with a history of panic attacks.
• A client who slept 2 to 3 hours last night because of flashbacks.
• A client pacing the halls and stating that his anxiety is an 8/10.
• A client diagnosed with generalized anxiety disorder awaiting discharge.
• Suicide precautions.

Rationale: Any client who is exhibiting hopelessness

or helplessness needs to be monitored closely for suicide intention A client diagnosed with panic attacks is being admitted for the fifth time in 1 year because of hopelessness and helplessness. Which precaution would the nurse plan to implement?

• Elopement precautions.
• Suicide precautions.
• Homicide precautions.
• Fall precautions.

• "I reminded myself that the panic attack would end

soon, and it helped."

Rationale: This statement is an indication that the

cognitive intervention was successful. By remembering that panic attacks are self- limiting, the client is applying the infor- mation gained from the nurse's cognitive intervention The nurse is using a cognitive intervention to decrease anxiety during a client's panic attack. Which client statement would indicate that the intervention has been successful?

• "I reminded myself that the panic attack would end soon, and it helped."
• "I paced the halls until I felt my anxiety was under control."
• "I felt my anxiety increase, so I took lorazepam (Ativan) to decrease it."
• "Thank you for staying with me. It helped to know staff was there."
• Clonidine hydrochloride (Catapres).
• Fluvoxamine maleate (Luvox).
• Buspirone (BuSpar).
• Alprazolam (Xanax).

Rationale:

• Clonidine hydrochloride (Catapres) an antihypertensive,

is used in the treatment of panic disorders and generalized anxiety

• Fluvoxamine maleate (Luvox), an anti-depressant, is

used in the treatment of obsessive-compulsive disorder.

• Buspirone (BuSpar), an anxiolytic, is used in the

treatment of panic disorders and generalized anxiety disorders.

• Alprazolam (Xanax), a benzodiazepine, is used for the

short-term treatment of anxiety disorders.Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply.

• Clonidine hydrochloride (Catapres).
• Fluvoxamine maleate (Luvox).
• Buspirone (BuSpar).
• Alprazolam (Xanax).
• Haloperidol (Haldol).
• Insomnia.
• Tremor.
• Delirium.

Which of the following symptoms are seen when a client abruptly stops taking diazepam (Valium)? Select all that apply.

• Insomnia.
• Tremor.
• Delirium.
• Dry mouth.
• Lethargy.
• Monitor for changes in mental status, diaphoresis,

tachycardia, tremor, and diarrhea.

Rationale: It is important for the nurse to monitor for

serotonin syndrome, which occurs when a client takes multiple medications that affect serotonin levels.Symptoms include change in mental status, restless- ness, myoclonus, hyperreflexia, tachycar- dia, labile blood pressure, diaphoresis, shivering, tremor, and diarrhea A client recently diagnosed with generalized anxiety disorder is prescribed clonazepam (Klonopin), buspirone (BuSpar), and citalopram (Celexa). Which assessment related to the concurrent use of these medications is most important?

• Monitor for signs and symptoms of worsening depression and suicidal ideation.
• Monitor for changes in mental status, diaphoresis, tachycardia, tremor, and

diarrhea.

• Monitor for hyperpyresis, dystonia, and muscle rigidity.
• Monitor for spasms of face, legs, and neck and for bizarre facial movements.

• "Sedation is a side effect of this low dose of trazodone.

It will help you sleep."

Rationale: Trazodone is an antidepressant and when

correctly, the test taker first has to under- prescribed at a low dose can be used to stand that sedative/hypnotics are metabo- improve sleep A client complains of poor sleep and loss of appetite. When prescribed trazodone (Desyrel) 50 mg qhs, the client states, "Why am I taking an antidepressant? I'm not depressed." Which nursing response is most appropriate?

• "Sedation is a side effect of this low dose of trazodone. It will help you sleep."
• "Trazodone is an appetite stimulant used to prevent weight loss."
• "Trazodone is an antianxiety medication that decreases restlessness at

bedtime."

• "Trazodone is an antipsychotic medication used off label to treat insomnia."
• An 80 year-old man diagnosed with a depressive

disorder.

• A 45 year-old woman diagnosed with alcohol use

disorder.

• A 25 year-old woman admitted to the hospital after a

suicide attempt.

• A 50 year-old man who has a diagnosis of Parkinson's

disease.

Rationale:

• An 80 year-old is at risk for injury, and giving this client a

central nervous system (CNS) depressant can increase the risk for falls.

• Benzodiazepines such as triazolam can be addictive.

Individuals diagnosed with alcohol use disorder may have increased risk of abusing a benzodiazepine and would need to be monitored closely. Alcohol is a central nervous system (CNS) depressant and if taken with a benzodiazepine, the client could experience an additive CNS depressant effect.

• CNS depressants such as triazolam increase depressive

symptoms. It would be important that the nurse monitor this cli-ent closely for suicidal ideations.

• A client who is diagnosed with Parkinson's disease is at

increased risk for injury because of altered gait and poor balance, and giving this client a CNS depressant can increase the risk for falls. This client needs to be monitored closely.Which of the following clients would have to be monitored closely when prescribed triazolam (Halcion) 0.125 mg qhs? Select all that apply.

• An 80 year-old man diagnosed with a depressive disorder.
• A 45 year-old woman diagnosed with alcohol use disorder. 3. A 25 year-old

woman admitted to the hospital after a suicide attempt.

• A 60 year-old man admitted after a panic attack.
• A 50 year-old man who has a diagnosis of Parkinson's disease.

• Encourage the client to take the medication

continuously as prescribed because onset of action is delayed 2 to 3 weeks.

Rationale: It is important to teach the client that the

onset of action for buspirone (BuSpar) is 2 to 3 weeks.Often the nurse may see a benzodiazepine, such as clonazepam (Klonopin), prescribed because of its quick onset of effect, until the buspirone begins working.Which teaching need is important when a client is newly prescribed buspirone (BuSpar) 5 mg tid?

• Encourage the client to avoid drinking alcohol while taking this medication

because of the additive central nervous system depressant effects.

• Encourage the client to take the medication continuously as prescribed

because onset of action is delayed 2 to 3 weeks.

• Encourage the client to monitor for signs and symptoms of anxiety to

determine the need for additional buspirone (BuSpar) prn.

• Encourage the client to be compliant with monthly lab tests to monitor for

medication toxicity

• Teach the client and family to monitor fasting blood

sugar levels daily at various times during treatment.

Rationale: Methylphenidate lowers the client's activity

level, which decreases the use of glucose and increases glucose levels. Because of this, it is necessary to monitor fasting blood sugar levels regularly.A client diagnosed with ADHD and juvenile diabetes is prescribed methylphenidate (Ritalin). Which nursing intervention related to both diagnoses takes priority?

• Teach the client and family that methylphenidate should be taken in the morning
• Teach the client and family to report restlessness, insomnia, and dry mouth.
• Teach the client and family to monitor fasting blood sugar levels daily at various

times during treatment.

• Teach the client and family that methylphenidate should be taken exactly as

prescribed.

• Methylphenidate (Concerta).
• Lisdexamfetamine (Vyvanse).
• Amphetamine/dextroamphetamine (Adderall).

Which of the following stimulant medications are prescribed in the treatment of ADHD? Select all that apply.

• Methylphenidate (Concerta).
• Guanfacine (Intuniv).
• Lisdexamfetamine (Vyvanse).
• Amphetamine/dextroamphetamine (Adderall).
• Clonidine (Catapres)
• The child is experiencing improved social interaction as

evidenced by making eye contact and allowing physical touch.

Rationale: By making eye contact and allowing physical

touch, this child is experiencing improved social interaction, making this an accurate evaluative statement.A child diagnosed with autism spectrum disorder has a nursing diagnosis of impaired social interaction. The child is currently making eye contact and allowing physical touch. Which statement addresses the evaluation of this child's behavior?

• The nurse is unable to evaluate this child's ability to interact socially based on

the observed behaviors.

• The child is experiencing improved social interaction as evidenced by making

eye contact and allowing physical touch.

• The nurse is unable to evaluate this child's ability to interact socially because the

child has not experienced these behaviors for an extended period.

• The child making eye contact and allowing physical touch are indications of

improved personal identity, not improved social interaction.