Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 135

1. A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

A) Assess level of consciousness
B) Assess suicide potential
C) Observe for sedation and hypotension
D) Orient to her room and unit rules

2. A clients record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

A) High carbohydrate, low cholesterol
B) High protein, high carbohydrate
C) 1 g sodium
D) Tyramine-free

3. Two weeks after a clients admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

A) Brain tumor or other space-occupying lesion
B) History of mitral valve prolapse
C) Surgically repaired herniated lumbar disk
D) History of frequent urinary tract infections

4. A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn - t that a lot?' The nurse - s best response is:

A) 'Yes, that does seem like a lot.'
B) 'You - ll have to talk to the doctor about that. The physician knows what - s best for the client.'
C) 'Six to 10 treatments are common. Are you concerned about permanent effects?'
D) 'Don - t worry. Some clients have lots more than that.'

5. A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse - s best response is:

A) 'You - ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.'
B) 'Visitors are not allowed. We will telephone you to inform you of her progress.'
C) 'There - s really no need to stay with her. She - s going to sleep for several hours after the treatment.'
D) 'Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.'

1. Right Answer: B
Explanation: (A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if comatose. (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicide assessment. (D) Orientation to room and unit rules is of low priority at this time.

2. Right Answer: D
Explanation: (A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods.When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.

3. Right Answer: A
Explanation: (A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.

4. Right Answer: C
Explanation: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husbands fears. (B) This response is'passing the buck' unnecessarily. The information needed to appropriately answer the husband s question is well within the nurse s knowledge base. (C) The most common range for affective disorders is 610 treatments. This response confirms and reinforces the physicians plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husbands underlying concerns about his wife.

5. Right Answer: D
Explanation: (A) It is within the nurses realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off.(D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

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