NCLEX Mental Health and Psychiatric Nursing 2 — Questions and Answers
Question 1: A client taking phenelzine (an MAOI) asks which food is safe to eat. Which response is correct?
- Aged cheddar cheese
- Fresh grilled chicken (Correct answer)
- Pepperoni pizza
- Sauerkraut
Correct answer: Fresh grilled chicken
Tyramine-rich foods like aged cheese, cured meats, and fermented products can trigger hypertensive crisis with MAOIs, while fresh chicken is safe.
Question 2: A client on lithium reports nausea, coarse tremor, and slurred speech. What is the nurse's priority action?
- Encourage fluids and continue the dose
- Hold the dose and obtain a lithium level (Correct answer)
- Administer the next dose early
- Reassure the client these are expected
Correct answer: Hold the dose and obtain a lithium level
Coarse tremor, slurred speech, and GI symptoms indicate lithium toxicity, so the nurse should hold the medication and check the serum level.
Question 3: Which therapeutic serum lithium range is considered safe for maintenance therapy?
- 0.1-0.5 mEq/L
- 0.6-1.2 mEq/L (Correct answer)
- 1.5-2.0 mEq/L
- 2.5-3.0 mEq/L
Correct answer: 0.6-1.2 mEq/L
The maintenance therapeutic range for lithium is 0.6-1.2 mEq/L, with toxicity rising above 1.5 mEq/L.
Question 4: A client experiencing a panic attack is hyperventilating and feels they are 'going to die.' What is the nurse's best initial intervention?
- Leave the client alone to calm down
- Stay with the client and speak in short, calm directions (Correct answer)
- Explain the neurochemistry of panic in detail
- Encourage the client to describe past traumas
Correct answer: Stay with the client and speak in short, calm directions
During a panic attack the nurse should remain present and use short, calm, simple directions to help the client regain control.
Question 5: A nurse is teaching about sertraline, an SSRI. Which symptom cluster should the client report immediately as possible serotonin syndrome?
- Dry mouth and constipation
- Agitation, hyperthermia, and muscle rigidity (Correct answer)
- Mild drowsiness and headache
- Increased appetite and weight gain
Correct answer: Agitation, hyperthermia, and muscle rigidity
Serotonin syndrome presents with agitation, hyperthermia, autonomic instability, and muscle rigidity and requires immediate attention.
Question 6: A client with anorexia nervosa is hospitalized. Which assessment finding is the most immediate concern?
- Lanugo on the arms
- Serum potassium of 2.5 mEq/L (Correct answer)
- Dry skin
- Cold intolerance
Correct answer: Serum potassium of 2.5 mEq/L
A potassium of 2.5 mEq/L is severe hypokalemia that can cause life-threatening cardiac arrhythmias and is the priority.
Question 7: Which communication technique demonstrates therapeutic use of silence?
- Filling pauses with questions
- Allowing the client time to reflect before responding (Correct answer)
- Changing the subject when uncomfortable
- Giving advice during quiet moments
Correct answer: Allowing the client time to reflect before responding
Therapeutic silence gives the client time to gather thoughts and reflect, signaling the nurse's willingness to listen.
NCLEX Mental Health and Psychiatric Nursing 2
A client taking phenelzine (an MAOI) asks which food is safe to eat.
Which response is correct?