Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 131
Questions 1. Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?A) Vitamin C and zincB) Folic acid and niacinC) Vitamin A and biotinD) Thiamine and pyroxidine2. The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the clients best choice from the items below would be:A) Liver and onions, macaroni and cheese, tea with sugarB) Baked chicken, baked potato with bacon bits, milkC) Waffles with butter and honey, orange juiceD) Cheese omelette with ham and mushrooms, milk3. A chronic alcoholic clients condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?A) HiccupsB) AnorexiaC) Mental confusionD) Fetor hepaticus4. The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:A) Decreasing nitrogen-forming bacteria in the intestinesB) Acidifying colon contents by causing ammonia retention in the colonC) Decreasing the uptake of vitamin D, thereby drawing more water into the colonD) Irritating the bowel and promoting evacuation of stool5. A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:A) Chloride level of 99 mEq/LB) Sodium level of 136 mEq/LC) Potassium level of 3.1 mEq/LD) Potassium level of 6.3 mEq/L Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine. (B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts.2. Right Answer: CExplanation: (A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.3. Right Answer: CExplanation: (A) Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma. (C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen. (D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails.4. Right Answer: AExplanation: (A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycins action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.5. Right Answer: DExplanation: (A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.55.0 mEq/L. .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 132
Questions 1. An IDDM clients condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:A) 8:30 AM - 10:30 AMB) 2:30 PM - 4:30 PMC) 7:30 PM - 9:30 PMD) 10:30 PM - 11:30 PM2. After several days, an IDDM clients serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:A) One frankfurterB) One ounce of hamC) Two slices of baconD) One-fourth cup dry cottage cheese3. When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:A) When exercise is increased, insulin needs are increasedB) When exercise is increased, insulin needs are decreasedC) When exercise is increased, there is no change in insulin needsD) When exercise is decreased, insulin needs are decreased4. A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:A) Acute urinary retentionB) Hesitancy in starting urinationC) Increased frequency of urinationD) Decreased force of the urinary stream5. A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress.The purpose of this bladder irrigation is to prevent:A) Bladder spasmsB) Clot formationC) Scrotal edemaD) Prostatic infection Right Answer and Explanation: 1. Right Answer: BExplanation: (A) This time describes the time of onset of NPH insulins action, rather than its peak effect. (B) NPH insulin, an intermediateacting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of NPH insulin peaks 814 hours after administration. It has a 2030 hour duration. (C) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM. (D) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM.2. Right Answer: DExplanation: (A) A frankfurter is a high-fat meat on the diabetic exchange list. (B) Ham is a medium-fat meat on the diabetic exchange list, unless it is a center-cut slice. (C)One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not between exchange lists.(D) Diabetic meat-exchange lists are categorized into leanmeat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange.3. Right Answer: BExplanation: (A) If the clients insulin is increased when activity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the clients insulin dose does not need to be altered unless the blood sugar becomes unstable.4. Right Answer: AExplanation: (A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.5. Right Answer: BExplanation: (A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication. .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 133
Questions 1. Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client - s sexual functioning?A) 'You may resume sexual intercourse in 2 weeks.'B) 'Many men experience impotence following TURP.'C) 'A transurethral resection does not usually cause impotence.'D) 'Check with your doctor about resuming sexual activity.'2. A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:A) Determination of multiple gestationsB) Determination of gross anomaliesC) Determination of placental locationD) Determination of fetal age3. A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:A) Thready pulseB) Irregular pulseC) TachycardiaD) Bradycardia4. A client is being admitted to the labor and delivery unit. She has had previous admissions for 'false labor.' Which clinical manifestation would be most indicative of true labor?A) Increased bloody showB) Progressive dilatation and effacement of the cervixC) Uterine contractionsD) Decreased discomfort with ambulation5. In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?A) A 31 patellar tendon reflexB) Respirations of 12 breaths/minC) Urine output of 40 mL/hrD) A 21 proteinuria value Right Answer and Explanation: 1. Right Answer: CExplanation: (A) Sexual activity should be delayed until cleared by the clients physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety.2. Right Answer: CExplanation: (A) Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the spinal needle used to obtain amniotic fluid. (D) Sonography can be used to determine fetal age. In this question, the sonogram is used as a preparatory step for a specific invasive procedure.3. Right Answer: DExplanation: (A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid. (B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D)Puerperal bradycardia with rates of 5070 bpm commonly occurs during the first 610 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.4. Right Answer: BExplanation: (A) Bloody show is considered a sign of imminent labor, which usually begins in 2448 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor.However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.5. Right Answer: BExplanation: (A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is
More detailsPublished - Thu, 23 Feb 2023
Created by - Jenny Clarke
NCLEX-RN Exam Questions - Part 134
Questions 1. A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:A) Lung immaturityB) Intrauterine growth retardation (IUGR)C) Intrauterine infectionD) Neural tube defect2. On admission to the postpartal unit, the nurses assessment identifies the clients fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right.This is most likely an indication of:A) Normal involutionB) A full bladderC) An infection painD) A hemorrhage3. A client - s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?A) Assess quantity of fluid.B) Assess color and odor of fluid.C) Document on fetal monitor strip and chart.D) Assess fetal heart rate (FHR).4. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:A) A low birth weightB) A birth defectC) AnemiaD) Nicotine withdrawal5. Which of the following blood values would require further nursing action in a newborn who is 4 hours old?A) Hemoglobin 17.2 g/dLB) Platelets 250,000/mm3C) Serum glucose 30 mg/dLD) White blood cells 18,000/mm3 Right Answer and Explanation: 1. Right Answer: AExplanation: (A) At about 3032 weeks gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.2. Right Answer: BExplanation: (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.3. Right Answer: DExplanation: (A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B)Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.4. Right Answer: AExplanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.5. Right Answer: CExplanation: (A) The normal range for hemoglobin in the newborn is 1719 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is150,000400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,00040,000/mm3 is normal in the newborn. .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 135
Questions 1. A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:A) Assess level of consciousnessB) Assess suicide potentialC) Observe for sedation and hypotensionD) Orient to her room and unit rules2. A clients record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?A) High carbohydrate, low cholesterolB) High protein, high carbohydrateC) 1 g sodiumD) Tyramine-free3. Two weeks after a clients admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?A) Brain tumor or other space-occupying lesionB) History of mitral valve prolapseC) Surgically repaired herniated lumbar diskD) History of frequent urinary tract infections4. A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn - t that a lot?' The nurse - s best response is:A) 'Yes, that does seem like a lot.'B) 'You - ll have to talk to the doctor about that. The physician knows what - s best for the client.'C) 'Six to 10 treatments are common. Are you concerned about permanent effects?'D) 'Don - t worry. Some clients have lots more than that.'5. A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse - s best response is:A) 'You - ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.'B) 'Visitors are not allowed. We will telephone you to inform you of her progress.'C) 'There - s really no need to stay with her. She - s going to sleep for several hours after the treatment.'D) 'Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.' Right Answer and Explanation: 1. Right Answer: BExplanation: (A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if comatose. (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicide assessment. (D) Orientation to room and unit rules is of low priority at this time.2. Right Answer: DExplanation: (A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods.When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.3. Right Answer: AExplanation: (A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.4. Right Answer: CExplanation: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husbands fears. (B) This response is'passing the buck' unnecessarily. The information needed to appropriately answer the husband s question is well within the nurse s knowledge base. (C) The most common range for affective disorders is 610 treatments. This response confirms and reinforces the physicians plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husbands underlying concerns about his wife.5. Right Answer: DExplanation: (A) It is within the nurses realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off.(D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment. .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 136
Questions 1. A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he - s going to cut out my heart.' The nurse - s best response is:A) 'I know you - re feeling frightened right now, but I want you to know that I don - t see anyone in the corner.'B) 'You - ll probably see strange things for a while until the PCP wears off.'C) 'Try to sleep. When you wake up, the devil will be gone.'D) 'You - re probably feeling guilty because you used illegal drugs tonight.'2. A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?A) Give fluids if the client requests them.B) Assess skin integrity and circulation of extremities before applying restraints and as they are removed.C) Measure vital signs at least every 4 hours.D) Release restraints every 2 hours for client to exercise.3. After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:A) Lorazepam (Ativan)B) Benztropine (Cogentin)C) Thiothixene (Navane)D) Flurazepan (Dalmane)4. Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:A) The physician orders itB) A therapeutic alliance has been established, and violent behavior subsidesC) The violent behavior subsides, and the client agrees to behaveD) The nurse deems that removal of restraints is necessary5. A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is5 - 4' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:A) Obtain an accurate weightB) Search the client - s purse for pillsC) Assess vital signsD) Assign her to a room with someone her own age Right Answer and Explanation: 1. Right Answer: AExplanation: (A) The nurse is the clients link to reality. This response validates the authenticity of the clients experience by casting doubt on his belief and reinforcing reality.(B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the clients feelings by offering a nontherapeutic interpretation of the motivation for the clients actions.2. Right Answer: DExplanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 12 hours. (D)Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.3. Right Answer: BExplanation: (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B)Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.4. Right Answer: BExplanation: (A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only 'agrees to behave' after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.5. Right Answer: CExplanation: (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority. .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 137
Questions 1. Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose'just 5 more lb.' Her symptoms are consistent with:A) PregnancyB) BulimiaC) GastritisD) Anorexia nervosa2. Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:A) Hypoglycemia from low-carbohydrate intakeB) Possible cardiac dysrhythmias secondary to hypokalemiaC) Dehydration from vomitingD) Anoxia secondary to anemia3. A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, 'I haven - t exercised in 6 days. I won - t be eating lunch today.' This statement by her most likely reflects:A) Her lack of internal awareness about the outcome of the behaviorB) Increased knowledge about personal exercise plansC) A manipulative technique to trick the nurse into allowing her to miss a mealD) A true desire to stay fit while in the hospital4. A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:A) 'Okay, missing one meal won - t hurt.'B) 'You - ll have to eat lunch, or we - ll force-feed you.'C) 'It - s not appropriate for you to try to manipulate the staff into granting your wishes.'D) 'We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.'5. A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:A) Allow her privacy at mealtimesB) Praise her for eating everythingC) Observe behavior for 1 - 2 hours after meals to prevent vomitingD) Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes Right Answer and Explanation: 1. Right Answer: DExplanation: (A) Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection. (D) All symptoms and vital signs are consistent with anorexia nervosa.2. Right Answer: BExplanation: (A) There is no lab data to support hypoglycemia. (B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in life-threatening dysrhythmias. (C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed. (D) The clients hemoglobin does not reflect a life threatening value sufficient to render the client anoxic.3. Right Answer: AExplanation: (A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the clients lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted. (B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition, exercise, and rest is absent. (C) The clients level of denial and lack of awareness disallow this behavior as a manipulative trick. (D)The clients illness-maintaining behaviors are inconsistent with fitness.4. Right Answer: DExplanation: (A) This response reinforces the clients maladaptive behavior, thereby contributing to the clients risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.5. Right Answer: CExplanation: (A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet. .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 138
Questions 1. A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:A) Be comforted when he is heldB) CryC) Not notice that his mother has leftD) Withdraw and become listless2. The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:A) 900 mL/24 hrB) 1300 mL/24 hrC) 1600 mL/24 hrD) 2000 mL/24 hr3. A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:A) CryingB) Falling asleepC) Rolling from his back to his tummyD) Sucking his thumb4. A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:A) Encourage him to drink plenty of fluidsB) Expect him to have nausea with vomitingC) Keep him awake for the next 12 hoursD) Wake him up every 1 - 2 hours during the night5. A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:A) Ask the physician to order a sedativeB) Have the client describe his headache every 15 minutesC) Increase his fluid intake to 3000 mL/24 hrD) Offer diversionary activities Right Answer and Explanation: 1. Right Answer: BExplanation: (A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.2. Right Answer: CExplanation: (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.3. Right Answer: AExplanation: (A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.4. Right Answer: DExplanation: (A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C)The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.5. Right Answer: DExplanation: (A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 20002400 mL daily. (D) Diversion may help the child to focus on a pleasant activity instead of on his headache. .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 139
Questions 1. An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:A) Has a sudden and severe increase in intracranial pressureB) Has sustained an internal injury in addition to the head injuryC) Is beginning to experience a dangerously high level of anxietyD) Is having intracranial bleeding2. The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:A) Call the doctor immediatelyB) Help her to blow her nose carefullyC) Test the discharge for sugarD) Turn her to her side3. A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:A) Evidence of perineal irritationB) Pulse fell from 102 to 96C) Pulse increased from 96 to 102D) Temperature rose to 102_F rectally4. The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig - s sign. The nurse expects her to react to discomfort if she:A) Dorsiflexes her ankleB) Flexes her spineC) Plantiflexes her wristD) Turns her head to the side5. The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:A) ConstipationB) HypothermiaC) SeizureD) Sunken fontanelles Right Answer and Explanation: 1. Right Answer: BExplanation: (A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.2. Right Answer: CExplanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.3. Right Answer: DExplanation: (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.4. Right Answer: BExplanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.5. Right Answer: CExplanation: (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles. .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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