Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 154

1. A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program.Nursing interventions for the teenager will most likely include:

A) Establishing routine tasks and activities around mealtimes
B) Administering medications such as lithium
C) Requiring the client to eat more during meals
D) Checking the client - s room frequently

2. A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

A) Accepting her present body image
B) Verbalizing realistic feelings about her body
C) Having an improved perception of her body image
D) Exhibiting increased self-esteem

3. A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse,'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:

A) Reaction formation
B) Rationalization
C) Splitting
D) Sublimation

4. A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, 'Nobody cares about the clients.' The nurse - s most effective response would be:

A) 'How can you say that I don - t care? We just met.'
B) 'What makes you think the nurses don - t care?'
C) 'You will feel differently about us in a few days.'
D) 'You seem angry. Tell me more about how you feel.'

5. A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

A) Thioridazine (Mellaril), lithium, and benztropine
B) Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
C) Sodium, potassium, and magnesium
D) Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)

1. Right Answer: A
Explanation: (A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control.(B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client 'eat more' at mealtimes increases the client s feelings of powerlessness.(D) Like the previous strategy, checking the clients room frequently contributes to the clients feelings of powerlessness.

2. Right Answer: B
Explanation: (A) This outcome criterion is inadequate because the term 'accepts' is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.

3. Right Answer: C
Explanation: (A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The clients comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify ones feelings, behaviors, or motives. The clients comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individuals inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The clients comment reveals that she is not engaging in sublimation.

4. Right Answer: D
Explanation: (A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the clients'splitting' behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client s emotions and the dynamics underlying 'splitting' behavior. (D) By simultaneously acknowledging the client s emotional intensity and gently challenging her'splitting' behavior, the nurse addresses the client s current distortions and prepares for further interventions with angry or ambivalent feelings.

5. Right Answer: B
Explanation: (A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.

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