Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 94

1. A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours.The planning of nursing care for a delirious client is based on which of the following premises?

A) The delirious client is capable of returning to his previous level of functioning.
B) The delirious client is incapable of returning to his previous level of functioning.
C) Delirium entails progressive intellectual and behavioral deterioration.
D) Delirium is an insidious process.

2. A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy.Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:

A) Have transient memory loss, confusion, andheadache
B) Be alert and oriented immediately after the treatment
C) Have insomnia for the first few days
D) Require no special care after the procedure

3. An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test.The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

A) A family member who is having marital problems and is regularly abusing alcohol
B) A person with adequate communication and coping skills who is employed by the family
C) A friend of the family who wants to help but is minimally competent
D) A lifelong friend of the client who is often confused

4. A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

A) Must use the least restrictive measure possible to control the behavior
B) Should put the client in seclusion until he promises to behave appropriately
C) Should apply full restraints until the behavior is under control
D) Should allow other clients to observe the acting out so that they can learn from the experience

5. The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

A) Month-old magazines that are provided by volunteers
B) Large maps and posters depicting area of current residence
C) A litter of kittens for the clients to pet
D) A library of biographical books

1. Right Answer: A
Explanation: (A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.

2. Right Answer: A
Explanation: (A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.

3. Right Answer: A
Explanation: (A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect.This individual has a vested interest in providing care.

4. Right Answer: A
Explanation: (A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.

5. Right Answer: B
Explanation: (A) This answer is incorrect. Current magazines would be appropriate. (B) This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. (C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. (D) This answer is incorrect. Biographies depict a past, not a present, orientation.

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