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NCLEX-RN Mental Health Questions

Extract:

The nurse in the intensive care unit (ICU) is caring for a 53-year-old male client.
Item 4 of 6
Nurses' Notes
Laboratory Results
1222: Client brought via ambulance to ED because of altered mental status and agitation. The client's wife reports that the client stopped drinking alcohol 'cold turkey' two days ago. This morning, the client was agitated, sweating, and altered. The client's wife reports that the client drinks 6-8 alcoholic beverages daily. On assessment, the client is alert and agitated. He recognizes that he is in the hospital but cannot recall the reasoning. Nystagmus was present. Skin is flushed and diaphoretic. Lung sounds are clear bilaterally. S1/S2 heart tones with mid-
systolic clicks. Peripheral pulses 1+. Abdomen is taut with normoactive bowel sounds. Vital signs: T 99.4°F (37.4°C), P 108. RR 18, BP 158/96, pulse oximetry 95% on room air. Medical history of hypertension, hyperlipidemia, and mitral valve prolapse. Home medications hydrochlorothiazide and multivitamin. EMS placed a 20-gauge peripheral vascular access device in the left antecubital space.
1239: Physician provided verbal order to obtain laboratory work (complete blood count, magnesium level, and basic metabolic panel). 1311: Laboratory results received and reviewed. The nurse updates the nurses' notes.


Question 1 of 5

For each potential order, click to specify whether the potential order is indicated or not indicated for the client.

Potential Orders Indicated Not Indicated
P.R.N. soft wrist restraints
serum type and screen
administration of a parenteral benzodiazepine
intravenous hypotonic fluids
continuous cardiac monitoring
strict fall precautions

Correct Answer: A: Not Indicated, B: Not Indicated, C: Indicated, D: Not Indicated, E: Indicated, F: Indicated, G: Indicated, H: Indicated, I: Indicated

Rationale: Benzodiazepines, cardiac monitoring, fall precautions, CIWA scale, thiamine, and psychiatric consultation are indicated for alcohol withdrawal management. Restraints, type and screen, and hypotonic fluids are not typically required.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Rationale:

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