Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 39
Questions 1. A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:A) Placing her in seclusion until the behavior is under controlB) Walking up to the client and touching her on the arm to get her attentionC) Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet areaD) Confronting the client, letting her know the consequences for getting angry and disrupting the unit2. A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:A) Transient depressionB) Mild depressionC) Moderate depressionD) Severe depression3. A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:A) Tell the client to attend all structured activities on the unitB) Encourage or direct client to attend activities that offer simple methods to attain successC) Increase the client - s self-esteem by asking that she make all decisions regarding attendance in group activitiesD) Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff4. A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, 'I just couldn - t take it anymore.' The nurse - s best response to this disclosure would be:A) 'You shouldn - t do things like that, just tell someone you feel bad.'B) 'Tell me more about what you couldn - t take anymore.'C) 'I - m sure you probably didn - t mean to kill yourself.'D) 'How long have you been in the hospital.'5. A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurses intervention would be to:A) Confront the client with the fact that she will have to eat more from her tray to sustain herB) Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutritionC) Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal timesD) Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Threatening a client with punitive action is violating a clients rights and could escalate the clients anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.2. Right Answer: DExplanation: (A) Transient depression manifests as sadness or the 'blues' as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. (C)Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about lifes failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression.3. Right Answer: BExplanation: (A) The nurse should encourage activities gradually, as clients energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the clients control; this sets up the client for further failure and possibly decreased self-worth. (D)Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.4. Right Answer: BExplanation: (A) Disapproving gives the impression that the nurse has a right to pass judgment on the clients thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the clients feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurses anxiety or insensitivity.5. Right Answer: DExplanation: (A) The manic clients mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. (B) Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and its best to avoid long discussions. (C) Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. (D) Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Fri, 03 Mar 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 40
Questions 1. Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the clients depression alert the nurse to prioritize problems and care by addressing which of the following problems first:A) Nutritional statusB) Impaired thinkingC) Possible harm to selfD) Rest and activity impairment2. The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:A) Hypertensive crisisB) Severe rashC) Severe hypotensionD) Severe diarrhea3. A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:A) Impaired communicationB) Sensory-perceptual alterationsC) Altered thought processesD) Impaired social interaction4. A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:A) Ideas of referenceB) Delusions of persecutionC) Thought broadcastingD) Delusions of grandeur5. A client experiencing delusions states, 'I came here because there were people surrounding my house that wanted to take me away and use my body for science.' The best response by the nurse would be:A) 'Describe the people surrounding your house that want to take you away.'B) 'I need more information on why you think others want to use your body for science.'C) 'There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.'D) 'I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.' Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine clients sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.2. Right Answer: AExplanation: (A) The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. (B) MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. (C) MAO inhibits false neurotransmitters (phenylalanines) and may produce hypotensive reactions from gradual accumulation of these neurotransmitters. (D) The most serious adverse reactions of MAO inhibitors involve blood pressure.3. Right Answer: BExplanation: (A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions.4. Right Answer: DExplanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.5. Right Answer: DExplanation: (A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the clients delusional system may force the client to defend it, and you cannot change the delusion through logic.(D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Fri, 03 Mar 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 41
Questions 1. A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:A) Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.B) Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.C) Do frequent room checks to be sure that the client is not hiding food or throwing it away.D) Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.2. A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I - m never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:A) 'The fact is you are an alcoholic or you wouldn - t be here.'B) 'I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free.'C) 'If you can stop drinking when you want to, why don - t you stop?'D) 'It - s good that you can stop drinking when you want to.'3. A 79-year-old client with Alzheimer - s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client - s care:A) Maintain routines and usual structure and adhere to schedules.B) Encourage the client to attend all structured activities on the unit, whether she wants to or not.C) Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.D) Give the client two or three choices to decide what she wants to do.4. The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?A) Approach the client on a continuum of least restrictive care.B) Challenge client - s behavior immediately with steps to prevent injury to self or others.C) Leave the aggressive client to himself or herself, and take other clients away.D) To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.5. When planning care for the passive-aggressive client, the nurse includes the following goal:A) Allow the client to use humor, because this may be the only way this client can express self.B) Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.C) Allow the client to have time away from therapeutic responsibilities.D) Allow the client to give excuses if he forgets to give staff information. Right Answer and Explanation: 1. Right Answer: AExplanation: (A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the clients need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.2. Right Answer: BExplanation: (A) Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. (B) A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. (C) Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. (D) Giving approval or placing a value on feelings or a behavior may limit the clients freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.3. Right Answer: AExplanation: (A) Alzheimers clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions.4. Right Answer: AExplanation: (A) Approaching a clients aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase clients internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone.The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.5. Right Answer: BExplanation: (A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed others efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Fri, 03 Mar 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 42
Questions 1. A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According toNgeles rule, the estimated date of confinement is:A) March 17B) June 3C) August 30D) January 102. At 16 weeks gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:A) Reinforce an incompetent cervixB) Repair the amniotic sacC) Evaluate cephalopelvic disproportionD) Dilate the cervix3. A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.The first intervention the RN should initiate is to:A) Place the examining table in the Trendelenburg positionB) Assess the client to see if she is having vaginal bleedingC) Obtain the client - s vital signs immediatelyD) Help the client to a sitting position4. At 30 weeks gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN - s answer should be:A) HyperglycemiaB) HypoglycemiaC) Lack of development of the intestinesD) Lack of development of the lungs5. At 30 weeks gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:A) HypoglycemiaB) HyperkalemiaC) TachycardiaD) Increase in hematocrit and hemoglobin Right Answer and Explanation: 1. Right Answer: AExplanation: (A) Using Ngeles rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect.2. Right Answer: AExplanation: (A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks gestation unless the pregnancy is to be terminated.3. Right Answer: DExplanation: (A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RNs first intervention should be one that helps to alleviate the clients symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the clients vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.4. Right Answer: DExplanation: (A) Any infant would be at risk for hyperglycemia because the infants liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infants liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infants liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth.5. Right Answer: CExplanation: (A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _- mimetics to activate hematopoiesis. .col-md-12 { -webkit-user-select: none; -ms-user-select: none; user-select: none; } .flash-sale-container{background:#134981;text-align:center;padding:2%;} p.flash-sale-text{ font-size:24px;font-family:"Poppins";letter-spacing:2px;line-height:1.4em; } span.flash-break{ display:block; } .flash-sale-text { -webkit-animation-name:flash; animation: blink 1.5s infinite; } @keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } @-webkit-keyframes blink{ 0% { color: #D3585F; } 20% { color: #D3585F; } 40% { color: #FFF; } 60% { color: #FFF; } 80% { color: #D3585F; } 100% { color: #D3585F; } } 80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
More detailsPublished - Fri, 03 Mar 2023
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