Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 122
Questions 1. A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:A) 'It - s God - s will. It was probably for the best. There was something probably wrong with your baby.'B) 'You - re young. You can have other children later.'C) 'I know your other children will be a great comfort to you.'D) 'I can see you - re upset. Would you like to see and hold your baby?'2. A client - s prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:A) In the immediate postpartum periodB) After the first trimesterC) At 28 weeks - gestationD) Within 72 hours postpartum3. A 24-year-old woman who is gravida 1 reports, 'I can - t take iron pills because they make me sick.' She continues, 'My bowels aren - t moving either.' In counseling her based on these complaints, the nurse - s most appropriate response would be, 'It would be beneficial for you to eat . . .A) prunes.'B) green leafy vegetables.'C) red meat.'D) eggs.'4. A 26-year-old female client presents at 10 weeks gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The clients previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?A) Age>25 yearsB) Maternal weightC) Previous birth of an infant weighing>9 lbD) Family history of heart disease5. The nurse assesses a clients monitor strip and finds the following: uterine contractions every 34 minutes, lasting 6070 seconds; FHR baseline 134146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?A) Notify physician of nonreassuring FHR pattern.B) Turn the client to her left side.C) Start IV for fetal distress and administer O2 at 6 - 8 liters by mask.D) Evaluate to see if the monitor strip is reassuring. Right Answer and Explanation: 1. Right Answer: DExplanation: (A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process.The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.2. Right Answer: AExplanation: (A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.3. Right Answer: AExplanation: (A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron- deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C)Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.4. Right Answer: CExplanation: (A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The clients weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.5. Right Answer: DExplanation: (A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician. (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions.During the active phase of labor, the frequency of uterine contractions is every 24 minutes, with an appropriate duration of 60 sec. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 123
Questions 1. Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:A) Decreasing her sodium intakeB) Decreasing her fluidsC) Increasing her carbohydrate intakeD) Eating a moderate to high-protein diet2. A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?A) 'It sounds as though you are coming down with a bad cold. I - ll ask the doctor to prescribe a decongestant for relief of symptoms.'B) 'A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'C) 'These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'D) 'This is most unusual. I - m sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'3. A newborn girls father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:A) Mild hypotonia is expected in the upper extremities.B) Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.C) Function progresses in a head-to-toe, proximal-distal fashion.D) Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.4. A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:A) Administer methergine IMB) Remove the retained placental fragmentsC) Assist the client to the bathroom and provide cues to stimulate urinationD) Massage the fundus until firm5. A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:A) Chadwick - s signB) FHR by ultrasoundC) Enlargement of the uterusD) Breast tenderness and enlargement Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. (B) Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. (C) Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. (D) Loss of urinary protein(proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension.Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.2. Right Answer: CExplanation: (A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. (B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. (C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. (D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.3. Right Answer: CExplanation: (A) Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. (B) Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. (C) Growth of the newborn progresses in a cephalocaudal, proximal- distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. (D) Asymmetrical movements of the extremities are indicative of neurological dysfunction.4. Right Answer: DExplanation: (A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.5. Right Answer: BExplanation: (A) Chadwicks sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 124
Questions 1. A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:A) SulfaB) TetracyclineC) HydralazineD) Erythromycin2. A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?A) Sitting with legs crossed at anklesB) Wearing thromboembolic disease (TED) stockingsC) Wearing support pantyhoseD) Wearing knee-high stockings3. A client at 9 weeks gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:A) An increased risk in maternal adaptation to pregnancyB) The need for anticipatory guidance regarding the pregnancyC) The need for teaching regarding family planningD) An increased risk for subsequent abortions4. A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse - s assessment of this response is:A) Initial maternal-infant bonding may be poor.B) Client may have a poor relationship with her husband.C) This response is normal in the first trimester.D) This response is abnormal, to be re-evaluated at the next visit.5. A client at 6 months gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:A) Iron-deficiency anemiaB) Physiological anemiaC) Fatigue due to stressD) No problem indicated Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Sulfa is a teratogen and will cause kernicterus. (B) Tetracycline is a teratogen and will effect tooth development. (C) Hydralazine is not an antibiotic but a calcium channel blocker. (D) Erythromycin is safe during pregnancy and can be used when the client is allergic to penicillin.2. Right Answer: DExplanation: (A) Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points. (B) TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. (C) Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. (D) Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.3. Right Answer: BExplanation: (A, D) There are no data to support this. (B) Anticipatory guidance and health maintenance is a first-line defense in the promotion of healthy mothers and healthy babies. (C) There are no data to support this at this time. This will be a concern later.4. Right Answer: CExplanation: (A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. (B) There are no data to support this. This statement by the mother still leaves room for exploration. (C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. (D) It is not abnormal. If it were, another month would also be too long to wait.5. Right Answer: AExplanation: (A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 125
Questions 1. In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?A) BackacheB) Leaking of clear yellow fluid from breastsC) Constipation with hemorrhoidsD) Visual changes2. The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold - s maneuvers by having her:A) Empty her bladderB) Lie on her left sideC) Place her arms over her headD) Force fluids 1 hour prior to procedure3. Before giving methergine postpartum, the nurse should assess the client for:A) Decreased amount of lochial flowB) Elevated blood pressureC) FlushingD) Afterpains4. A 24-hours postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:A) Assist her with a sitz bathB) Administer the prescribed medication for painC) Teach her Kegel exercisesD) Apply an ice pack5. The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:A) Wear gloves for the procedureB) Place and adjust the pad from back to frontC) Cleanse and wipe the perineum from front to backD) Protect the outer surface of the pad from contamination Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.2. Right Answer: AExplanation: (A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam.The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.3. Right Answer: BExplanation: (A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.4. Right Answer: AExplanation: (A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy.They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.5. Right Answer: CExplanation: (A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions.(B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 126
Questions 1. In teaching the client about proper umbilical cord care, the nurse recommends that:A) Petrolatum be placed around the cord after the sponge bathB) A belly binder be applied to prevent umbilical herniaC) The area be cleansed at diaper changes with alcohol and inspected for redness or drainageD) The cord clamp be left on until the cord stump separates2. A baby is circumcised. Immediate postoperative care should include:A) Applying a loose diaperB) Keeping the baby NPO for 4 hours to avoid vomitingC) Changing the dressing frequently using dry, sterile gauzeD) Taking the baby to his mother for cuddling3. A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks gestation, all of the following observations are made. Which would require intervention?A) Weight gain of 2 kg in 4 weeksB) Blood pressure of 128/78C) Subjective data: shortness of breath after showeringD) Ankle edema reported present in late afternoon and evenings4. A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?A) Contractions every 2 minutes, lasting 100 secondsB) Fetal heart decelerations during a contractionC) Beat-to-beat variability between contractionsD) Fetal heart decelerations at the beginning of contractions5. A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:A) Place her in knee-chest position during the contractionB) Use effleurage during the contractionC) Apply strong sacral pressure during the contractionD) Have her push with each contraction Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.2. Right Answer: DExplanation: (A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby.Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.3. Right Answer: CExplanation: (A) This is not an excessive weight gain indicative of fluid retention. (B) The blood pressure is within normal range. (C) Showering should not cause shortness of breath. This could be a sign ofcardiac decompensation. (D) Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.4. Right Answer: AExplanation: (A) These are tetanic in nature and can cause rupture of the uterus. (B) The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. (C) Beat-to-beat variability is a normal finding and demonstrates fetal well-being. (D) The FHR may decrease at the beginning of a contraction owing to head compression.5. Right Answer: CExplanation: (A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head.(D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 127
Questions 1. The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the clients diet?A) Cream cheeseB) Fresh fruitsC) Aged cheeseD) Yeast bread2. A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?A) High fever, tachycardia, stupor, renal failureB) Lip smacking, chewing, blinking, lateral jaw movementsC) Photosensitivity, orthostatic hypotension, dry mouthD) Constipation, blurred vision, drowsiness3. On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?A) Administer her next dosage of lithium, and then call the physician.B) Withhold her lithium, and report her symptoms to the physician.C) Place her on NPO to decrease the excretion of lithium from her body, and call the physician.D) Contact the lab and request a lithium level in 30 minutes, and call the physician.4. In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms.In addition to the lithium, which one of the following medications might the physician prescribe?A) Diazepam (Valium)B) Haloperidol (Haldol)C) Sertraline (Zoloft)D) Alprazolam (Xanax)5. The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?A) DementiaB) ParkinsonismC) DeliriumD) Mania Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine.2. Right Answer: BExplanation: (A) These symptoms are found in clients with neuroleptic malignant syndrome. (B) These symptoms are found in clients with tardive dyskinesia. (C) These are normal side effects found in clients taking antipsychotic medications. (D) These are also normal side effects found in clients taking antipsychotic medications.3. Right Answer: BExplanation: (A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death.The nurse needs further orders from the physician to stabilize the clients lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the clients lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.4. Right Answer: BExplanation: (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.5. Right Answer: AExplanation: (A) These changes are common characteristics of dementia. (B) Parkinsons disease affects the muscular system. Progressive memory changes are not presenting symptoms. (C) Delirium includes an altered level of consciousness, which is not found in dementia. (D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 128
Questions 1. A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?A) Always allow the most vocal person to state the problem first.B) Encourage the mother to speak for the children.C) Interpret immediately what seems to be going on within the family.D) Allow family members to assume the seats as they choose.2. In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?A) Crisis intervention with an intoxicated teenager whose mother just committed suicideB) Referring a client who has been on a detoxification unit to a rehabilitation centerC) Teaching fifth-grade children the harmful effects of substance abuseD) Counseling a client with post-traumatic stress disorder3. While the nurse is taking a male client - s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:A) Politely tells the client, 'Keep your hands off 'B) Ignores the remarks and hopes he will not try it againC) Confronts the remarks but attempts not to reject the clientD) Leaves the room in order to compose herself4. A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?A) Promises of gifts that her husband made to herB) Acute battering of the client, characterized by his volatile discharge of tensionC) Minor battering incidents, such as the throwing of food or dishes at herD) A period of tenderness between the couple5. Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?A) Fine hand tremor, headache, mental dullnessB) Vomiting, impaired consciousness, decreased blood pressureC) Polyuria, polydipsia, edemaD) Gastric irritation, nausea, diarrhea Right Answer and Explanation: 1. Right Answer: DExplanation: (A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions.(B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D)Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.2. Right Answer: CExplanation: (A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.3. Right Answer: CExplanation: (A) This response does not recognize normal feelings of attraction and rejects the client. (B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.4. Right Answer: CExplanation: (A) This description is characteristic of the 'honeymoon' or 'respite' phase. (B) This description is characteristic of the 'battering' phase. (C) This description is characteristic of the 'tension- building' phase prior to the volatile discharge of tension found in the battering phase. (D) This description is characteristic of the'honeymoon' or 'respite' phase.5. Right Answer: BExplanation: (A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium. (B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 129
Questions 1. A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?A) Antipsychotic medicationsB) Antidepressant medicationsC) Antianxiety medicationsD) Antimania medication2. The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:A) 'I know it was my fault that it happened, because I shouldn - t have been out so late.'B) 'If I had not worn that sexy dress that night, he wouldn - t have raped me.'C) 'I know my date just had so much passion he couldn - t handle me saying - no. - 'D) 'I know now that it was not my fault, but I want to continue counseling after my discharge.'3. A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:A) 'I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group.'B) 'I know that I can only drink one or two drinks at social gatherings in the future, but at least I don - t have to continue AA.'C) 'I really wasn - t addicted to alcohol when I came here, I just needed some help dealing with my divorce.'D) 'It really wasn - t my fault that I had to come here. If my wife hadn - t left, I wouldn - t have needed those drinks.'4. Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?A) 'Some folks believe that aging causes this, Mother.'B) 'Perhaps, it - s the way your parents used those double- bind messages, Mother.'C) 'I know some people who are having this problem and they were exposed to chemicals at work, Mother.'D) 'It can be caused by lots of things, toxic agents and even alcohol, Mother.'5. A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?A) The parts of a system are only minimally related.B) Dysfunction in one part affects every other part.C) A family system has no boundaries.D) Healthy families are enmeshed. Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors.(C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).2. Right Answer: DExplanation: (A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapists behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.3. Right Answer: AExplanation: (A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support himAlcoholicsAnonymous. (B) The client is still using denial and is not dealing with his alcohol addiction. (C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce. (D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction.4. Right Answer: BExplanation: (A) Aging is a factor in the cause of degenerative disorders. (B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to degenerative disorders. (C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders. (D) Alcohol causes some degenerative disorders, such as Wernickes syndrome.5. Right Answer: BExplanation: (A) The parts of a system are interrelated. (B) Any change in any part of the system affects all other parts. (C) A family system, like any other system, has boundaries. (D) Healthy families are neither enmeshed nor disengaged. .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 - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 130
Questions 1. The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her sons condition by which of the following statements?A) 'Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.'B) 'Has anyone in your family ever had schizophrenia?'C) 'If your son has a twin, he probably will eventually develop schizophrenia, too.'D) 'Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.'2. A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurses most therapeutic response will be:A) 'I don - t see your mother in the room. Let - s talk about how you - re feeling.'B) 'OK, I - ll come back later when you - re feeling more like taking your medicine.'C) 'She may be here, but I can - t see her.'D) 'Why don - t you finish talking to her, and I - ll wait.'3. A female client with major depression stated that 'life is hopeless and not worth living.' The nurse should place highest priority on which of the following questions?A) 'How has your appetite been recently?'B) 'Have you thought about hurting yourself?'C) 'How is your relationship with your husband?'D) 'How has your depression affected your daily livingactivities?'4. A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurses assessment of her behavior would most likely be:A) Deep depressionB) Psychotic depressionC) Severe anxietyD) Severe depression5. A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis.His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?A) Lifting heavy objectsB) Walking brisklyC) Ingestion of barbituratesD) Ingestion of antacids Right Answer and Explanation: 1. Right Answer: AExplanation: (A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother.2. Right Answer: AExplanation: (A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B)This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.3. Right Answer: BExplanation: (A) Although eating habits are important to assess, they are less important than suicidal intent. (B) Maintenance of the clients life is the priority; assessment of suicidal intent is imperative. (C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent. (D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although this information may give additional information about the actual plan for a suicidal attempt.4. Right Answer: DExplanation: (A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself. (B) She is not manifesting psychotic symptoms in her behaviors. (C) The clients symptoms are more indicative of depression than anxiety. (D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.5. Right Answer: AExplanation: (A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure. .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 - Thu, 23 Feb 2023
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