Questions 97

NCLEX-RN

NCLEX-RN Test Bank

Mental Health RN NCLEX Questions Questions

Extract:


Question 1 of 5

After administering naloxone (Narcan), an opioid antagonist, the nurse should monitor the client carefully for which of the following?

Correct Answer: D

Rationale: Naloxone can precipitate withdrawal, and its effects may wear off, leading to recurrent respiratory depression, which requires close monitoring.

Question 2 of 5

A client commonly jumps when spoken to and reports feeling uneasy. The client says, 'It's as though something bad is going to happen.' In which order from first to last should the following nursing actions be done?

Order the Items

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Teach problem solving strategies.
Ask the client to deep breathe for 2 minutes.
Discuss the client's feelings in more depth.
Reduce environmental stimuli.

Correct Answer: D,B,C,A

Rationale: First reduce stimuli, then use deep breathing, discuss feelings, and finally teach problem-solving to manage anxiety.

Question 3 of 5

A client on a stretcher in the emergency department begins to thrash around, slap the sheets and yells, 'Get these bugs off of me.' She is disoriented and has a blood pressure of 189/75 and a pulse of 96. The friend who is with her says, 'She was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any.' The nurse should do the following in which order from first to last?

Order the Items

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Obtain an order to place the client in restraints, if needed.
Implement constant observation.
Monitor vital signs every 15 minutes.
Administer haloperidol (Haldol) and lorazepam (Ativan) I.M. as ordered.
Remind the client that she is in the hospital and the nurse is with her.
Chart the client's response to the interventions.

Correct Answer: B,E,D,A,F

Rationale: First implement observation, orient the client, monitor vital signs, administer medications, consider restraints if needed, and chart responses.

Question 4 of 5

When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse should assess the client for the ability to demonstrate which of the following?

Correct Answer: D

Rationale: When coping is dysfunctional enough for hospitalization, the client is likely demonstrating minimal functioning with new problems developing, indicating a need for comprehensive assessment and intervention. Objective problem solving is unlikely in this state, tension reduction may be a goal but not the primary assessment focus, and anger management is too specific for the broad assessment needed.

Question 5 of 5

In which of the following situations can a client's confidentiality be breached legally?

Correct Answer: C

Rationale: Confidentiality can be breached legally when there is a duty to warn, such as when a client threatens harm to others, as this prioritizes public safety. Sharing with a spouse, in a student paper, or with an employer violates confidentiality unless specific consent is given.

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