Psychiatric Nursing: Psychopharmacology

30-Item NCLEX-NGN Clinical Judgment Examination

30 minutes

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1. A client newly prescribed sertraline reports that depressive symptoms have not improved after four days. Which response by the nurse is most appropriate?

A. The medication should already have produced its primary therapeutic effect. B. Some symptoms may improve before the full antidepressant effect becomes evident. C. The absence of improvement indicates that the prescribed dose is ineffective. D. The medication should be discontinued until depressive symptoms intensify.

Rationale: Antidepressants generally require several weeks for their full therapeutic effect. Early changes may occur before substantial improvement in mood.

2. A client taking lithium asks which laboratory functions are especially important during ongoing treatment. Which response is best?

A. Serum calcium and pancreatic enzymes provide the primary monitoring strategy. B. Liver enzymes and platelet counts provide the most direct monitoring strategy. C. White-cell counts and coagulation studies provide routine dose guidance. D. Renal and thyroid function are important because lithium affects both systems.

Rationale: Lithium is eliminated by the kidneys and can affect thyroid function. Renal and thyroid monitoring are important during therapy.

3. The nurse receives four reports about clients receiving psychotropic medications. Which client should the nurse assess first?

A. A client receiving clozapine with fever and a new sore throat. B. A client receiving fluoxetine who reports decreased appetite. C. A client receiving lithium who reports mild thirst between meals. D. A client receiving lorazepam who reports fatigue after dosing.

Rationale: Fever and sore throat in a client receiving clozapine may indicate neutropenia or agranulocytosis and require prompt assessment.

4. A client taking haloperidol develops severe muscular rigidity, altered consciousness, diaphoresis, and rapidly increasing temperature. Which interpretation is most appropriate?

A. The findings most strongly suggest an expected extrapyramidal response. B. The findings are most consistent with worsening psychotic symptoms. C. The findings require concern for neuroleptic malignant syndrome. D. The findings indicate that therapeutic dopamine blockade has been achieved.

Rationale: Severe rigidity, hyperthermia, autonomic instability, and altered mental status are characteristic warning findings for neuroleptic malignant syndrome.

5. Which task is most appropriate for the RN to delegate to experienced unlicensed assistive personnel?

A. Determine whether a client is developing medication-induced akathisia. B. Obtain routine vital signs from a stable client after medication administration. C. Evaluate whether a client understands prescribed medication risks. D. Decide whether a sedated client requires additional observation.

Rationale: Routine data collection for a stable client may be delegated. Assessment, interpretation, teaching, and clinical judgment remain with the RN.

6. A client taking lithium develops vomiting and diarrhea. Which findings should increase the nurse's concern for lithium toxicity?

A. New coarse hand tremor B. Mild thirst after routine activity C. Repeated vomiting with continued diarrhea D. Slight increase in appetite at breakfast E. New unsteady gait while walking F. Mild fatigue after an interrupted night's sleep

Rationale: Dehydration can increase lithium accumulation. Coarse tremor and ataxia are concerning neurologic manifestations of lithium toxicity.

7. Four clients receiving antidepressants are being assessed. Which finding requires the most immediate intervention?

A. A client taking escitalopram reports delayed orgasm. B. A client taking venlafaxine reports reduced appetite. C. A client taking sertraline has agitation, clonus, fever, and diaphoresis. D. A client taking bupropion reports difficulty falling asleep.

Rationale: Agitation, clonus, hyperthermia, and diaphoresis strongly suggest serotonin toxicity, which can become life-threatening.

8. A competent client refuses an antipsychotic because of unacceptable adverse effects. Which nursing action best protects the client's rights?

A. Explore the refusal, provide relevant information, and notify the prescriber. B. Ask another staff member to administer the medication later. C. Document noncompliance and proceed because the medication was prescribed. D. Tell the client that refusal will result in loss of treatment privileges.

Rationale: A competent client has the right to refuse treatment. The nurse should assess the reason, provide information, respect autonomy, and communicate the concern.

9. A client taking clozapine reports extreme fatigue, fever, and painful swallowing. Which action is most appropriate?

A. Encourage fluids and reassess after the next scheduled dose. B. Administer the medication with food to reduce gastrointestinal effects. C. Interpret the symptoms as an expected consequence of sedation. D. Promptly assess for infection and follow the required blood-monitoring protocol.

Rationale: Fever and painful swallowing may indicate infection associated with clozapine-induced neutropenia. Prompt evaluation is required.

10. A newly admitted client requires teaching about lithium toxicity and medication interactions. Which action should remain with the RN?

A. Recording the client's oral intake during the shift. B. Explaining how dehydration can increase medication-related risk. C. Obtaining the client's current weight using a calibrated scale. D. Reporting that the client consumed half of breakfast.

Rationale: Medication teaching requires nursing knowledge and clinical judgment and should remain with the RN.

11. A client taking an SSRI is being evaluated for serotonin toxicity. Which findings most strongly support this concern?

A. Gradual weight gain without acute symptoms B. Hyperreflexia accompanied by inducible clonus C. Mild constipation occurring intermittently D. Stable appetite with unchanged sleep pattern E. Mild dry mouth without neurologic changes F. Agitation accompanied by diaphoresis

Rationale: Hyperreflexia, clonus, agitation, and diaphoresis are characteristic findings associated with serotonin toxicity.

12. A client with bipolar disorder receives an antidepressant and mood stabilizer. The client becomes increasingly energetic and sleeps two hours nightly. Which interpretation is best?

A. The new activation may represent emerging mania requiring reassessment. B. The increased energy demonstrates that the antidepressant is fully effective. C. The reduced sleep indicates that depressive symptoms are resolving normally. D. The increased activity suggests that medication adherence has improved.

Rationale: Markedly decreased need for sleep and increased energy can signal emerging mania. The medication regimen requires reassessment.

13. A client taking an atypical antipsychotic gains 7 kg and develops increased fasting glucose and triglycerides. Which interpretation is best?

A. The changes are unrelated because atypical antipsychotics primarily affect dopamine. B. The pattern warrants metabolic-risk assessment and treatment-team collaboration. C. The findings demonstrate that therapeutic concentration has been reached. D. The changes can be ignored unless extrapyramidal symptoms develop.

Rationale: Several second-generation antipsychotics can cause weight gain and metabolic abnormalities. These changes warrant assessment and follow-up.

14. Which client should the psychiatric nurse assess first?

A. A client receiving quetiapine who reports increased appetite. B. A client receiving buspirone who reports mild dizziness. C. A client receiving fluoxetine who reports delayed ejaculation. D. A client receiving lithium who develops confusion and severe tremor.

Rationale: Confusion and severe tremor may indicate significant lithium toxicity and acute neurologic deterioration.

15. A client prescribed phenelzine reports severe headache and palpitations after eating several aged foods. Which action should the nurse prioritize?

A. Assess blood pressure promptly and treat the symptoms as a potential hypertensive emergency. B. Reassure the client that cardiovascular changes are expected with antidepressants. C. Encourage the client to rest and continue the medication as scheduled. D. Explain that dietary restrictions are unnecessary after treatment begins.

Rationale: MAOIs can interact with tyramine-containing foods and cause severe hypertension, headache, and cardiovascular complications.

16. A client is starting a benzodiazepine for severe anxiety. Which teaching points should the nurse include?

A. Avoid combining the medication with alcohol. B. Use caution with activities requiring alertness. C. Take additional doses whenever anxiety suddenly increases. D. Dependence and withdrawal risk increase with prolonged use. E. Stop treatment abruptly once symptoms become manageable. F. Report excessive sedation or unusual difficulty staying awake.

Rationale: Benzodiazepines can cause CNS depression and impaired alertness. Alcohol can intensify sedation. Prolonged use can cause dependence and withdrawal.

17. A client receiving an antipsychotic asks for an explanation of the medication before taking it. Which response best supports informed decision-making?

A. Medication explanations are primarily the prescriber's responsibility. B. Refusing medication may interfere with discharge planning. C. The prescription itself establishes the need for treatment. D. Provide appropriate medication information and verify understanding.

Rationale: Nurses have a responsibility to provide appropriate medication information and support informed participation in treatment.

18. A client taking risperidone develops repetitive lip smacking and tongue movements several months after treatment begins. Which interpretation is most appropriate?

A. The findings are most consistent with acute dystonia. B. The findings raise concern for tardive dyskinesia. C. The findings indicate therapeutic sedation from the medication. D. The findings are most consistent with serotonin toxicity.

Rationale: Repetitive involuntary oral-facial movements developing after prolonged antipsychotic exposure are concerning for tardive dyskinesia.

19. A client taking valproate develops unusual abdominal pain, repeated vomiting, and marked weakness. Which interpretation should guide the nurse's next action?

A. The symptoms most likely represent a temporary adjustment to sedation. B. The findings are expected during the first phase of mood stabilization. C. The presentation warrants prompt evaluation for a serious medication complication. D. The symptoms should be managed by taking the medication with a larger meal.

Rationale: Significant abdominal pain and vomiting during valproate therapy require prompt evaluation because pancreatitis and hepatotoxicity are serious potential complications.

20. Which activity should the RN retain rather than delegate?

A. Determining whether a newly confused client may have medication toxicity. B. Recording the percentage of a stable client's meal consumed. C. Obtaining a routine blood pressure from a stable client. D. Reporting that a client requested assistance with ambulation.

Rationale: Determining whether confusion represents medication toxicity requires assessment and clinical judgment and therefore remains with the RN.

21. A client receiving serotonergic medications develops agitation, hyperreflexia, clonus, and diaphoresis. Which finding is the strongest additional clue supporting serotonin toxicity?

A. Gradual increase in appetite B. Mild dry mouth after dosing C. Rapidly increasing body temperature D. Mild constipation without abdominal pain E. Stable sleep pattern throughout treatment F. Gradual weight gain over several months

Rationale: Hyperthermia in the setting of agitation, hyperreflexia, clonus, and diaphoresis strongly supports serotonin toxicity.

22. A client taking fluoxetine says, "I feel better, so I will stop it tonight." Which nursing response is most appropriate?

A. Stopping immediately is reasonable once depressive symptoms improve. B. Taking the medication only when symptoms return is acceptable. C. Reducing the medication independently prevents most problems. D. Medication changes should be discussed with the prescriber before stopping.

Rationale: Clients should not independently discontinue psychiatric medications. Medication changes should be discussed with the prescriber.

23. The nurse receives four reports. Which finding should be addressed first?

A. A client taking an SSRI reports mild nausea after breakfast. B. A client taking quetiapine reports daytime drowsiness. C. A client taking haloperidol develops sudden neck spasm and difficulty swallowing. D. A client taking buspirone reports mild headache after dosing.

Rationale: Sudden neck spasm and difficulty swallowing can represent acute dystonia involving the airway and require immediate assessment.

24. A client prescribed bupropion reports several nights with almost no sleep, escalating activity, and unusually rapid speech. What is the best nursing interpretation?

A. The change may indicate activation or mood switching requiring reassessment. B. The pattern confirms optimal therapeutic antidepressant activation. C. The reduced sleep shows that depression has completely resolved. D. The increased activity indicates that the medication should automatically be increased.

Rationale: Marked activation, decreased need for sleep, and rapid speech can signal emerging mania or hypomania and warrant reassessment.

25. A client taking lithium asks what factors can alter lithium safety. Which responses should the nurse include?

A. Significant fluid loss can increase the risk of lithium accumulation. B. Some medications can alter renal handling of lithium. C. Increasing sodium restriction is routinely recommended during treatment. D. Major changes in usual fluid intake can affect lithium concentrations. E. Taking extra doses can compensate safely for missed medication. F. Maintaining a relatively consistent fluid and sodium intake is important.

Rationale: Dehydration and changes in fluid or sodium balance can affect lithium concentrations. Several medications can also alter renal handling of lithium.

26. A legally competent client refuses a medication because of a previous severe adverse reaction. The prescriber insists that it be administered. What should the nurse do?

A. Administer the medication because the prescriber accepts responsibility. B. Ask another nurse to administer it so the refusal is not assigned to you. C. Tell the client that refusal is not permitted after prescription. D. Clarify the order and refusal before administration and escalate the safety concern.

Rationale: A competent client's refusal must be respected. The nurse should clarify the situation, assess safety, document appropriately, and escalate unresolved concerns.

27. A client taking an antipsychotic reports an inability to remain seated and repeatedly paces. Which assessment best helps distinguish akathisia from worsening psychosis?

A. Determine whether the client has experienced increased appetite since treatment began. B. Determine whether the client has developed increased daytime sleepiness. C. Ask whether the restlessness feels internally driven and difficult to suppress. D. Ask whether the client has noticed gradual changes in body weight.

Rationale: Akathisia involves subjective inner restlessness accompanied by observable motor activity. Asking about the internal sensation helps identify the condition.

28. A client is prescribed clozapine. Which ongoing concerns should the nurse incorporate into the monitoring plan?

A. Infection-related symptoms B. Severe constipation or bowel dysfunction C. Metabolic changes such as weight or glucose abnormalities D. New involuntary movements or other neurologic changes E. Increasing tolerance to ordinary environmental noise F. Occasional preference for taking medication with food

Rationale: Clozapine requires broad safety monitoring, including infection risk, gastrointestinal hypomotility, metabolic effects, and neurologic adverse effects.

29. A client taking an antipsychotic develops fever, severe rigidity, confusion, and autonomic instability. Which additional finding would most strongly support the suspected medication emergency?

A. Mild increase in appetite after starting treatment. B. Occasional difficulty falling asleep after evening dosing. C. Mild dry mouth without changes in mental status. D. Markedly elevated creatine kinase associated with muscle injury.

Rationale: Neuroleptic malignant syndrome can cause severe muscle injury and markedly elevated creatine kinase in addition to hyperthermia, rigidity, altered mental status, and autonomic instability.

30. A client is discharged with a newly prescribed psychotropic medication. Which nursing actions best support safe medication management after discharge?

A. Confirm that the client understands major adverse effects requiring urgent evaluation. B. Encourage the client to modify the dose whenever symptoms fluctuate. C. Review important interactions, precautions, and follow-up monitoring. D. Tell the client that psychiatric medications are safe once the first dose is tolerated. E. Suggest skipping doses whenever expected adverse effects become inconvenient. F. Verify that the client knows when and where required follow-up will occur.

Rationale: Safe psychiatric medication management includes recognition of serious adverse effects, understanding interactions and precautions, and adherence to required follow-up monitoring.

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Pediatric Nursing: Growth and Development

Pediatric Nursing: Growth and Development

30-item Growth and Development Quiz

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