NCLEX Psychosocial Integrity 4

Question 1

A client with anorexia nervosa is on day 3 of nutritional rehabilitation. Which lab result requires the nurse's immediate action?

Accepted Answer

Serum phosphorus 1.8 mg/dL

Answer

Hypophosphatemia is the hallmark of refeeding syndrome and can cause cardiac failure, respiratory failure, and death.

Question 2

A client taking lithium has a serum level of 2.0 mEq/L and reports vomiting and a coarse hand tremor. What is the nurse's priority action?

Accepted Answer

Hold the next dose and notify the provider

Answer

A level of 2.0 mEq/L with GI symptoms and coarse tremor indicates moderate toxicity, so lithium must be held and the provider notified.

Question 3

A client prescribed phenelzine selects foods for lunch. Which choice shows a need for more teaching?

Accepted Answer

Salami sandwich with aged cheddar

Answer

Cured meats and aged cheeses are high in tyramine, which can trigger a hypertensive crisis with MAOIs.

Question 4

A client receiving haloperidol has a temperature of 104°F (40°C), lead-pipe muscle rigidity, diaphoresis, and fluctuating blood pressure. What should the nurse do first?

Accepted Answer

Withhold the antipsychotic and notify the provider

Answer

These findings suggest neuroleptic malignant syndrome, a medical emergency that requires stopping the antipsychotic immediately.

Question 5

A client with borderline personality disorder praises some staff members and calls others cruel and incompetent. Which intervention is most appropriate?

Accepted Answer

Have all staff consistently enforce the same limits and care plan

Answer

Splitting is best handled by a consistent team approach with clear, uniformly enforced limits.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Psychosocial Integrity 4