NCLEX Questions Psych & TB

A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods? 1. Sneezing 2. Shaking hands 3. Contact with stool 4. Contact with urine

1. Sneezing Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine.

A nurse is collecting information from a client about the client's suicide risk. The nurse should ask the client which most significant question? 1. "Why do you want to hurt yourself?" 2. "Do you have a plan to commit suicide?" 3. " Has anyone in your family committed suicide?" 4. Can you describe how you are feeling right now?"

2. "Do you have a plan to commit suicide?" Rationale: When collecting information about suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 1, 3 and 4 do not directly provide this information.

A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse plans to schedule the medication: 1. With lunch. 2. At bedtime. 3. After breakfast. 4. Before breakfast.

2. At bedtime Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. Its side effects include sedation, dizziness, ataxia and confusion. When the client is taking this medication as a single dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety.

A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when: 1. Five sputum cultures are negative 2. Three sputum cultures are negative 3. The PPD and chest x-ray are negative 4. A sputum culture and a PPD test are negative

2. Three sputum cultures are negative Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary.

Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted? 1. A history of diabetes mellitus 2. Use of phenelzine sulfate (Nardil) 3. A history of myocardial infarction 4. A history of irritable bowel syndrome

2. Use of phenelzine sulfate (Nardil) Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI) such as phenelzine sulfate, MAOIs should be stopped at least 14 days before sertraline therapy. Conversely, sertraline should be at least 14 days before MAOI therapy. Options 1, 3, and 4 are not concerns of use of this medication.

A client who has been admitted to the mental health unit with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client has become enraged and has started to bite and kick the roommate for occupying the bathroom. Which of the following actions should the nurse take first? 1. Physically restrain the client 2. Notify the risk management department 3. Provide a safe environment for both clients 4. Administer a medication to provide chemical restraint

3. Provide a safe environment for both clients Rationale: The first action of the nurse is to provide an environment that is safe for both clients. This may take a variety of forms, depending on the individual circumstance, agency protocols, and written physician orders. Seclusion, chemical restraint, and physical restraint are used only when alternative and less restrictive measures are not effective in controlling the client's behavior.

A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room? 1. Draw the shades closed 2. Give the client a bedpan 3. Put up the side rails on the bed 4. Turn the volume on the television set down

3. Put up the side rails on the bed Rationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure himself or herself. The most frequent side effects of this medication are dizziness, drowsiness and lethargy. Therefore the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2 and 4 may be helpful measures that provide a comfortable, restful environment; however, option 3 is the only one that provides for the client's safety needs.

A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk? 1. Day shift 2. Weekdays 3. Shift change 4. 8 am to 2 pm

3. Shift change Rationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of increased risk for suicides are weekends (not weekdays), and the night shift (not day shift).

A nurse is collecting data about the lethality risk of a suicidal client. Which of the following is the best question for the nurse to ask the client? 1. "Do you have a death wish?" 2. "Do you wish your life was over?" 3. "Do you ever think about ending it all?" 4. "Have you ever thought of killing yourself?"

4. "Have you ever thought of killing yourself?" Rationale: A lethality assessment requires direct communication between the client and nurse. It is important to provide a question that is directly related to lethality. Options 1, 2 and 3 do not directly address the subject of the question. Option 4, is the most direct option.

Which statement made by a nursing student indicates an understanding of the concepts associated with suicide and suicide intentions? 1. "Only psychotic individuals commit suicide." 2. "Suicide attempts are just attention-seeking behaviors." 3. "Suicide runs in the family, so there is nothing that health care personnel can do about it." 4. "Many individuals who really do kill themselves have talked about their intentions to others."

4. "Many individuals who really do kill themselves have talked about their intentions to others." Rationale: Most people who commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic or even mentally ill. A suicide attempt is not an attention-seeking behavior, and each act should be taken seriously. Suicide is not an inherited condition; it is an individual condition.

A registered nurse (RN) tells a licensed practical nurse (LPN) that a client who is suspected of having tuberculosis (TB) is being admitted to the hospital and asks the LPN to prepare a room for the client. The LPN prepares the room, knowing that this client's room needs to provide which of the following? 1. Venting to the roof and ultraviolet light 2. Ultraviolet light and three room air exchanges per hour 3. Ten room air exchanges per hour and venting to the roof 4. Venting to the outside, six room air exchanges per hour, and ultraviolet light

4. Venting to the outside, six room air exchanges per hour, and ultraviolet light Rationale: The client with tuberculosis must be admitted to a private room that provides at least six air exchanges per hour. The room should provide venting to the outside and have ultraviolet lights installed. Options 1, 2 and 3 are inaccurate and would not provide adequate protection to help prevent transmission of the infection.

A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first? 1. Aspirate the tube 2. Flush the tube with warm water 3. Prepare to remove and replace the tube 4. Flush with a carbonated liquid such as cola

1. Aspirate the tube Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful.

A nurse employed in a physician's office is asked to check the client who is at low risk for contracting tuberculosis for the results of the purified derivative (PPD) implanted 72 hours previously. The nurse reads the PPD as measuring 11 mm induration in diameter. Which action should the nurse take next? 1. Notify the physician 2. Ask the client for permission to repeat the test 3. Document the normal finding in the client's record 4. Tell the client to make an appointment with a pulmonologist

1. Notify the physician Rationale: An area of induration that measures 10 mm is considered a positive reading and indicates exposure to tuberculosis (TB). The nurse who observes a positive PPD reading notifies the physician immediately. The physician would then order a chest x-ray to determine whether the client has clinically active tuberculosis or old, healed lesions. A sputum culture would then be done to confirm a diagnosis of active TB. Option 3 is incorrect because the reading is not a normal finding. Option 2 is incorrect because the test results are positive. The physician, not a nurse would request a consultation with a pulmonologist.

A nurse is implementing measures to prevent the spread of infection to other clients. The nurse understands that which of the following is the best way to prevent the spread of infection? 1. Use proper hand washing techniques 2. Use sterile technique with all procedures 3. Never stop in the middle of performing a procedure 4. Read the policy and procedure manual before performing treatments

1. Use proper hand washing techniques Rationale: Proper hand washing is the best way to prevent the spread of infection. All procedures do not require sterile technique. Reading the policy and procedure manual does not guarantee that infection will not be spread. It may be necessary in some events to stop in the middle of performing a procedure, but option 3 is not the best way to prevent the spread of infection.

A nurse is assisting in planning the discharge of a client with chronic anxiety and assists in selecting the goals that will promote a safe environment at home. The appropriate maintenance goal should focus on which of the following? 1. Ignoring feelings of anxiety 2. Identifying anxiety-producing events 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily events

2. Identifying anxiety-producing events Rationale: Recognizing events that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing events, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from daily activities.

A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients on the unit. The licensed practical nurse (LPN) consults with the registered nurse knowing that which of the following changes should be made to the client's treatment plan? 1. Allow increased "in room" activities 2. Increase the level of suicide precautions 3. Allow the client to spend time off the unit 4. Reduce the dosage of antidepressant medication

2. Increase the level of suicide precautions Rationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase in the level of suicide precautions is indicated to keep the client safe. The other options are not indicated (option 1) or could place the client at increases risk (options 3 and 4).

A psychotic client is belligerent and agitated, making aggressive gestures and pacing in the hallway. To ensure a safe environment, which of the following is the nurse's highest priority? 1. Assist other staff in restraining the client 2. Provide safety for the client and other clients on the unit 3. Provide comfort and consolation to other clients on the unit 4. Ask the client politely to calm down and regain control over his or her behavior

2. Provide safety for the client and other clients on the unit Rationale: A psychotic client who is out of control may require seclusion to ensure the safety of the client and other clients in the unit. The correct option is the only one that addresses the safety needs of both the client and others. Options 1 and 3 do not provide for the client's safety needs or rights, respectively. In addition, specific policies and guidelines must be followed with regard to restraining a client. Option 4 may be ineffective and does not address the safety needs of others in the unit.

A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client? 1. Measuring the pH of gastric aspirate 2. Submerging the NG tube in water to check for bubbling 3. Aspirating the NG tube with a 50 mL syringe for gastric contents 4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach

2. Submerging the NG tube in water to check for bubbling Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.

A physical assessment of the suicidal client is performed on admission to the inpatient unit. The nurse reviews the findings and recognizes that this is an important part of the admission process because it alerts the nurse to: 1. Baseline data 2. Abnormalities 3. Existing medical problems 4. Evidence of physical self-harm

4. Evidence of physical self-harm Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the formulation of a plan for the suicide attempt. Although all of the options are correct, option 4 is the most appropriate for the suicidal client. Clients with a history or evidence of self-harm are greater suicide risks.

A client who does not have an artificial airway has a new order for a sputum culture. The nurse should avoid doing which of the following to obtain a suitable specimen? 1. Obtaining the specimen early in the morning 2. Having the client take deep breaths before coughing 3. Asking the client to rinse the mouth before expectoration 4. Placing the culture container lid face down on the bedside table

4. Placing the culture container lid face down on the bedside table Rationale: The lid would be contaminated if it is placed face down on the bedside table, which could lead to inaccurate test results. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for the best sputum production. The specimen is optimally obtained early in the morning because sputum has a longer amount of time to collect in the airways during sleep.