Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 142

1. A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:

A) Grandiose delusions
B) Paranoid delusions
C) Auditory hallucinations
D) Visual hallucinations

2. A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

A) Sensory-perceptual alteration: auditory command hallucinations
B) Alteration in thought processes: paranoid delusions
C) Potential for violence directed at others
D) Impaired verbal communication: loose associations

3. A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

A) 'I understand that the voices are real to you, but I want you to know I don - t hear them. They are a symptom of your illness.'
B) 'Just don - t pay attention to the voices. They - ll go away after some medication.'
C) 'You can - t leave here. This unit is locked and the doctor has not ordered your discharge.'
D) 'We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'

4. The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:

A) The client will settle down more quickly if he thinks the staff is medicating him
B) The medication will sedate the client until the physician arrives
C) Haloperidol is a minor tranquilizer and will not oversedate the client
D) Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client

5. Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:

A) Parkinsonism and dystonia
B) Dystonia and akathisia
C) Akathisia and parkinsonism
D) Neuroleptic malignant syndrome

1. Right Answer: B
Explanation: (A) There are no indications that the clients thoughts reflect special powers or talents characteristic of grandiosity. (B) The clients thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions. (C, D) The client is not demonstrating a sensory experience.

2. Right Answer: C
Explanation: (A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations.

3. Right Answer: A
Explanation: (A) This response validates the clients experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the clients verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the clients potential for violence and loss of control. (D) This response is also threatening. The clients behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.

4. Right Answer: D
Explanation: (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.

5. Right Answer: B
Explanation: (A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. (C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.

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