NCLEX QUIZ QUESTIONS FOR T&E 671-695

695 - The client is unwilling to go out of the house for fear of doing something crazy in public. Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

1) Agoraphobia. 2) Hematophobia. 3) Claustrophobia 4) Hypochondriasis.

693 - The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

1) Ask direct questions to encourage talking. 2) Leave the client alone and intermittently check on him. 3) Sit beside the client in silence and verbalize occasional open ended questions. 4) Take the client into the day room with other clients so they can help watch him.

679 - The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the RN and expects that the RN will take which action?

1) Call the client's family. 2) Contact the HCP. 3) Persuade the client to stay a few more days. 4) Tell the client that discharge is not possible at this time.

681 - Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion b/c of uncontrollable feelings. The nurse reports the findings to the RN and expects that the RN will take which action?

1) Call the client's family. 2) Place the client in seclusion immediately. 3) Inform the client that seclusion has not been prescribed. 4) Get a written prescription from the HCP and obtain an informed consent.

690 - Which nursing intervention are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

1) Communicate expected behaviors to the client. 2) Ensure that the client knows that he/she is not in charge of the nursing unit. 3) Assist the client in developing means of setting limits on personal behavior. 4) Follow through about the consequences of behavior in a nonpunitive manner. 5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6) Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

676 - A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "let me out! There's nothing wrong with me! I don't belong here! The nurse identifies this behavior is which?

1) Denial. 2) Projection 3) Regression 4) Rationalization

677 - A client says to the nurse, I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

1) Have you shared your feelings with your family? 2) I think we should talk more about your anger with your family. 3) You're feeling angry that your family continues to hope for you to be cured. 4) Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia.

685- The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, How is Carol doing? She is my best friend and is seen at your clinic every week. Which is the appropriate response?

1) I cannot discuss any client situation with you. 2) I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she is doing great. 3) You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand. 4) I'm not supposed to discuss this, but since you are my neighbor, I can tell you she really has some problems.

687 - The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?

1) I know you feel they are out to get you, but it's not true. 2) I can hear the voice, and she wants you to come to dinner. 3) Sometimes people hear things or voices others can't hear. 4) I talked to the voices you're hearing and they won't hurt you now.

672 - The nurse assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

1) ID the client's ability to function. 2) ID the client's potential for self harm. 3) Inquiring about the client's feelings that may affect coping. 4) Inquiring about the client's perception of the cause of the neighbor's death.

689 - A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy. The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

1) It sounds as though you need to speak to the psychiatrist. 2) Perhaps you'd like to see the ECT room and speak to the staff. 3) Your child has decided to have this treatment. You should be supportive of the decision. 4) It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have.

694 - A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. she states that her daughter "stashes food, eats all the wrong things that make her hyperactive and hangs out with the wrong crowd. In helping the mother prepare for the daughters discharge, the nurse should suggest which?

1) Mom should restrict the daughter's socializing time with her friends. 2) The mother should restrict the amount of chocolate and caffeine products in the home. 3) The mother should keep her daughter out of school until she can adjust to the school environment. 4) The mother should consider taking time from work to help her daughter readjust to the home environment.

686 - A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?

1) Move the client next to the nurse's station. 2) Use a night light and turn off the TV 3) Keep the TV and soft light on during the night. 4) Play soft music during the night and maintain a well lit room.

691 - The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states which?

1) My meds won't make me anxious. 2) I'll go to support group and talk so that I won't hurt anyone. 3) I won't get anxious or hear things if I get enough sleep and eat well. 4) I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone.

682 - The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you? Which is the appropriate nursing response?

1) No, I won't tell anyone. 2) I cannot promise to keep a secret. 3) If you tell me the secret, I will tell it to your doctor. 4) If you tell me the secret, I will need to document it in your record.

671 - The nurse assigned to care for a client experienced disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

1) Open ended questions and silence. 2) Focusing on self disclosure regarding food preferences. 3) Stating the reasons that the client may not want to eat. 4) Offering opinions about the necessity of adequate nutrition.

684 - The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

1) Plan short-term goals. 2) ID expected outcomes 3) Assist in making appropriate referrals 4) Assist in developing realistic solutions.

688 - The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

1) Poor dietary choices. 2) Lack of exercise and poor diet. 3) Inadequate dietary intake and dehydration. 4) Psychomotor retardation and side effects of medication.

692 - The nurse observes that a client is psychotic, pacing and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

1) Provide safety for the client and other clients on the unit. 2) Provide the clients on the unit with a sense of comfort and safety. 3) Assist the staff in caring for the client in a controlled environment 4) Offer the client a less-stimulating area to calm down and gain control.

683 - The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are the therapeutic communication techniques? Select all that apply.

1) Restating. 2) Listening. 3) Asking the client "why" 4) Maintaining neutral responses. 5) Giving advice or approval or disapproval. 6) Providing acknowledgement and feedback

680 - A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?

1) The client presents a harm to self. 2) The client requested the admission. 3) The client consented to the admission 4) The client provided written application to the facility for admission.

678 - The nurse in a psyche unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

1) The client will be angry and will refuse care. 2) The client will participate in the treatment plan. 3) The client will be very resistant to treatment measures. 4) The client's family will be very resistant to treatment measures.

673 - The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should ID which as a priority concern?

1) The client's report of not eating or sleeping. 2) The presence of bruises on the client's body. 3) The client's report of self destructive thoughts. 4) The family member is disapproving of the treatment.

674 - Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory tech approaches the client to obtain a specimen of the client's blood, the client begins to shout "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

1) The technician will leave and come back later for your blood. 2) What makes you think that the tech wants to hurt you? 3) Are you fearful and think that others may want to hurt you? 4) The technician is not going to hurt you but it is going to help you.

675 - An intoxicated client is brought to the ED by local police. The client is told that the HCP will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?

1) Watch the behavior escalate before intervening. 2) Attempt to talk to the client to de-escalate the behavior. 3) Offer to take the client to an exam room until he or she can be treated. 4) Inform the client that he or she will be asked to leave if the behavior continues.