RN NCLEX study quiz

A nurse asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It's raining cats and dogs?'" What is the charge nurse's best response? - "I was attempting to get the client to admit to being afraid of cats and dogs." - "I am assessing the concreteness of the client's form of thought." -"Phrases like this one will help the client improve their abstract thinking ability." - "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving."

"I am assessing the concreteness of the client's form of thought."

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? - Available support system - Perception of the situation - Desire to return to work - Coping mechanisms.

Coping mechanisms.

The behavioral health nurse is providing crisis intervention follow-up with a client and is teaching concepts regarding crises. Which statement by the client would best indicate understanding of the teaching? - "I must have a type of mental illness because I was not able to cope with the stressful situation." - "I will usually not be able to identify a stressor that can cause a crisis in my life." - "This crisis has the potential to help me grow psychologically." - "Because this situation created a crisis for me, I can expect this crisis to recur for me."

"This crisis has the potential to help me grow psychologically."

A new nurse is anxious about being assigned to a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? - "What you really mean is that you fear a client with violent episodes." - "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." - "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." - "You attended an in-service during orientation on dealing with the client with violent behavior."

"Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes."

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? - "Don't be afraid because I will not let you fall." - "Your doctor says you must walk twice today." - "I'll get another nurse to help so you won't fall." - "What worries you most about getting out of bed."

"What worries you most about getting out of bed."

The nurse has been educating a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? - "I will avoid caffeine from now on." - "When I feel anxious I will increase my breathing to get more oxygen to my brain." - "I will go for a brisk walk when I begin to feel anxious." - "I will keep a diary of anxiety attacks to determine what triggers them."

"When I feel anxious I will increase my breathing to get more oxygen to my brain."

The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now." Which response by the nurse is therapeutic? "You are feeling all alone." "Why do you say you are lonely?" "Your feelings of loneliness will decrease." "I know other people who lost someone feel this way."

"You are feeling all alone.:"

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? - "I wouldn't worry about that; everything will be all right." - "You are worried that you may be responsible for your friend's condition?" - "How come you were drinking and driving?" - "Let's not talk about that right now."

"You are worried that you may be responsible for your friend's condition?"

The psychiatric nurse notices a new client sitting alone in the dayroom, shaking and muttering indistinguishable words. What statement by the nurse is appropriate? - "Who are you talking to?" - "You look like you are cold." - "It is always cold in this room." - "Do you want to get a sweater?"

"You look like you are cold."

An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? - Adaptive and coping skills for dealing with loss - Intellectual capacity to make personal decisions - Socioeconomic status for independent living - Spiritual awareness for emotional comfort.

- Adaptive and coping skills for dealing with loss.

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? - Blood urea nitrogen. (BUN) - Thyroid stimulating hormone (TSH) - Electroencephalogram (EEG) - Alanine Aminotransferase (ALT) - Electrocardiogram (ECG)

- BUN - TSH - ECG - it is vital to verify that the client has no undiagnosed renal, thyroid, or cardiac problems.

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? Select all that apply. - Mild disorientation - Difficulty with words or numbers - Poor personal hygiene - Agitation - Visual agnosia - Dysgraphia

- Mild disorientation - Difficulty with words and numbers.

The nurse manager of an Alzheimer's unit has completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? Select all that apply. - Use a firm touch to guide the client to a different location when needed - Be persistent when getting the client to do something. - Provide simple directions using gestures or pictures - Do not argue with the client - Play memory games to decrease dementia - Require participation in daily activities.

- Provide simple directions using gestures or pictures. - Do not argue with the client.

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? Select all that apply. - Abstract reasoning - Waxy flexibility - Grandiose delusions - Anxiety - Agitated behavior.

- Waxy flexibility - Grandiose delusions - Anxiety - Agitated behavior.

Psychological concreteness

Literal interpretation of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. The client with schizophrenia would have great difficulty describing the abstract meaning of, "It's raining cats and dogs."

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache." While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? - Ask the student about the bruises on the arms and ears. - Do nothing as bruises are common in 5 year old children. - Report the injuries immediately to the parents - Discuss the findings with the child's teacher.

Ask the student about the bruises on the arms and ears.

What statement by the nurse would be most appropriate for a client who is exhibiting signs of escalating anger? d - You seem angry, but I can't understand why you would be upset - I notice that you are angry. Please share what you are thinking - You need to calm down. You will make the other clients upset. - I am not going to be able to talk to you if you keep getting angry like this.

I notice that you are angry. Please share what you are thinking.

A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? - I will keep a diary of times of stress and the appearance of physical symptoms - I will simply ignore any physical symptoms I get from now on - The best way for me to stop having physical symptoms is to avoid all the stress in my life - I will take a sedative when I start having physical symtpoms.

I will keep a diary of times of stress and the appearance of physical symptoms.

A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? Encourage the client to watch TV with the other clients on the unit. Engage the client in a game of ping pong. Suggest that the client play monopoly with other clients Provide soft lighting in the client's room for reading.

Provide soft lighting in the client's room for reading.

A nurse is assessing a terminally ill client who is restless with an O2 saturation of 58 mm Hg. Which nursing intervention would the nurse implement? - Monitor the client's breathing pattern - Wipe the mouth with oral care sponge - Soothe the client by affirming your presence. - Initiate oxygen via nasal cannula at 4 L/minute.

Soothe the client by affirming your presence.

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take? - Obtain assistance to restrain the client - Talk quietly to the client - Administer haloperidol - Leave until the family can calm the client down.

Talk quietly to the client.

The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none in the past 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? - I am feeling better so I hope that I don't have to take the medication for long. - I can stope the medication after I have been out of the hospital for a year - The medicine is good for me now; however, I don't want to take it forever. - The medication keeps me out of the hospital, and I don't want to hear voices again.

The medication keeps me out of the hospital, and I don't want to hear voices again.

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental." The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? - The right to refuse photos of the wound - The right to refuse a blood alcohol test - The right to refuse a tetanus injection - The right to refuse police notification.

The right to refuse police notification.

The primary healthcare provider (PHP) informs a client that cancer was identified in the large intestine, and surgery should be scheduled as soon as possible. After the PHP leaves the room, the client turns their head away from the nurse and begins to cry. Which action by the nurse is appropriate? - Exit the room quietly - Touch the client's shoulder - Notify the client's family - Begin preoperative instruction.

Touch the client's shoulder.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? - You are wanting your sons to assist you in deciding about treatment options - It is really your decision about which option you choose. - I will be happy to discuss this issue with you. - This shows that you are proud of your sons.

You are wanting your sons to assist you in deciding about treatment options.

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate.? - Calm down first, and then I will call your therapist? - It's against the rules to call in the middle of the night - You must be distressed to want to talk at this late hour - That's a valid request, but it must wait until morning.

You must be distressed to want to talk at this late hour.