NCLEX study 3

The nurse admits a client diagnosed with alcohol withdrawal syndrome AWS. The client ingested the last drink 4 days ago. The nurse anticipates the onset of which symptom?

Fever

The nurse provides care for a client admitted with a diagnosis of acute myocardial infarction. The clients spouse tells the nurse about an anxiety disorder that the client has been self medicating with alcohol. It is most important for the nurse to assess for which symptoms?

Tachycardia, generalized tremors, and hypertension.

The nurse provides care for clients in an outpatient psychiatric unit. The parent of a client diagnosed with antisocial personality disorder says to the nurse, "my child seems much better and seems to be growing up and willing to accept more responsibility." Which response by the nurse is best?

Tell me about the responsibilities your child has accepted

The nurse supervises hospice care for a client who practices orthodox Judaism. Which observation indicates to the nurse that the care of this client is appropriate?

The client has a continuous intravenous morphine infusion

The nurse evaluates a client's response to a 2 week trial of electroconvulsive therapy. Which data indicates to the nurse that treatment is successful?

The client is no longer mute and withdrawn

The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy. Which finding does the nurse report to the health care provider?

The client takes alendronate once a day

The nurse in the outpatient mental health clinic develops a plan of care for a client diagnosed with bulimia. The nurse determines that which goal is most important?

The client will identify symptoms of electrolyte imbalance

A client diagnosed with terminal cancer has been placed in hospice care. The family has been informed that the client is not expected to live more than 3 months. Which statement, if made by the client's spouse, indicates the clients prognosis was correctly understood?

Hospice care will make my spouse feel more comfortable

The nurse provides care to a client diagnosed with a terminal illness. In which order will the nurse expect the client to demonstrate the stages of grief as described by Kubler-Ross?

Denial anger bargaining depression acceptance

The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining what precipitates the clients eating disorder?

Assign the client a food/feelings/thoughts action journal

The nurse visits the home of a family whose mother died 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1. A 3-year-old explains that mother is sleeping at grandmother's house. 2. A 6-year-old experiences enuresis and temper tantrums. 3. A 9-year-old states that no one will play with him. 4. A 12-year-old spends time away from home with friends.

A 9 year old states there is no one to play with

The nurse performs a physical assessment on a client diagnosed with bulimia nervosa. Which finding warrants an immediate referral to the health care provider?

A horse voice that is barely audible

A nurse from a mental health clinic offers a workshop on child maltreatment to the health care teach in the ED>.Which statement by an ED nurse indicates understanding?

A lack of knowledge of the childs needs by the parents may be a contributing factor in child neglect an injury that does not match the description of how it happened is a warning sign of abuse

The nurse provides teaching for a client newly diagnosed with diabetes. How does the nurse best assess the clients style of learning?

Ask the client how personal learning best occurs

The nurse on the psychiatric unit notices that a client diagnosed with depression does not eat meals. Which response by the nurse is appropriate?

Ask the client to identify favorite foods

An older adult client diagnosed with alcoholism receives chlordiazepoxide for 2 days for symptom management. The client says to the nurse, "get those bugs off of me!" Which action does the nurse take?

Assess the client for tachycardia and tremors

The nurse provides care for a client diagnosed with paranoid schizophrenia. The clients spouse states that the client has not slept in 3 nights. Which action does the nurse take?

Establish a trusting nurse client relationship

The nurse provides care for a client diagnosed with impaired vision. Which intervention will the nurse implement to meet the clients needs?

Explain the sounds of the environment Stay in the clients field of vision Identify self by name and staff position

The nurse manager educates nurses about how to communicate properly with clients diagnosed with dementia who have difficulty remembering recent events. When practicing, which statement by a nurse indicates that additional education is needed?

Good Evening! Would you like to share with me what you have been doing today?

THe psychiatric nurse is preparing a plan of care for clients who are survivors of intimate partner violence. Which type of therapy is best for this group of clients?

Group therapy

A client undergoes admission to the hospital with an acute myocardial infarction. The clients spouse states, "there has been an issue with heavy drinking for years." Based on this data, the nurse observes the client for which symptoms?

Hyperalertness, easily startled, anorexia

The nurse in the community mental health center talks individually with a client diagnosed with generalized anxiety disorder and who has been attending center programs for 4 months. Which statement made by the client best indicates that the anxiety is resolving?

I am sleeping 7 hours a night and my dreams are calm

The nurse in the outpatient psychiatric clinic is meeting in a room with a client. Another client diagnosed with antisocial personality disorder comes into the room and sits down. Which response by the nurse is best?

I am talking with this client. Please return to the waiting room.

The nurse makes a home visit to an older adult client who has a live in caregiver. Which statement by the caregiver requires further assessment by the nurse?

I love my client, but I feel like I am the only one who cares and it is overwhelming I never have time to see my friends. I just crave contact outside of this house I dont have any interest in things I used to enjoy. My only purpose is providing care I Get annoyed with all the demands, but no one else is going to take care of my client

A client has been hospitalized for major depression. Which client statement indicates to the nurse that the client is recovering?

I plan to take everything one day at a time and set boundaries I ordered a grilled cheese sandwich, tomato soup, and a hazelnut coffee for lunch

The school nurse conducts a workshop on eating disorders for teens. Which participant statement indicates to the nurse correct understanding of the teaching?

I will set healthy goals for my food and fluid intake I will write down what I'm eating and how I'm feeling

The nurse evaluates an older adult client whose spouse died a year ago. Which statement by the client would indicate that grief from the loss is subsiding?

I've come to terms that my spouse is gone forever I used to be mad at my spouse for dying I'm feeling good about getting back to work I went to dinner with friends and was able to enjoy myself I miss my spouse but i love being a grandparent

An adolescent client presents to the clinic for a follow up after a recent diagnosis of substance used disorder. Which client statement indicates to the nurse that SUD education was effective?

It is very normal if I relapse. I will try again if it happens and will reach out for help. I can reduce my cravings and triggers by getting involved in extracurricular school activities

The parent of a child client recently diagnosed with hemophilia A is talking to the pediatric nurse. Which statement from the parent dose the nurse respond to first?

It scares me to think my child will be bleeding all the time.

The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement?

Keep the room organized and clean

The nurse provides care to a client diagnosed with bipolar disorder. The client is experiencing a manic episode. Which intervention does the nurse implement to promote therapeutic interaction with the client?

Redirecting the client and reducing stimuli

The nurse completes an initial assessment on a client who is a possible victim of physical abuse. Which statement by the client will the nurse document as a priority concern?

Sometimes, I think of just not waking up.

A client of Hindu faith is diagnosed with terminal small cell lung cancer. The client states, "I dont want to die in the hospital. It is not in line with my spiritual values." Which is the best response by the nurse?

Tell me more about your spiritual values related to dying.

The nurse provides care for clients on the psychiatric unit. Which behavior indicates the client is beginning to develop a trusting relationship with the nurse?

The client discusses personal feelings with the nurse

After a client completed 6 months of multidisciplinary treatment for anorexia nervosa, the nurse evaluates whether the client has met the goal of balanced nutrition sufficient to meet metabolic demands. Which is the best indicator that the goal has been met?

The clients menstrual period has returned and is regular

The nurse on the behavioral health unit negotiates a behavior modification contract with an adolescent client diagnosed with anorexia nervosa. The nurse determines further teaching is necessary when the client makes which statement?

The faster I gain weight, the faster I will return to school

The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, "My father died of meningitis decades ago. Now my child may died of the same thing." Which is the best initial response by the nurse?

The outlook for meningitis is better now that it was then

A client recovering from ECT therapy is upset by an inability to remember what was eaten for dinner the evening before the treatment. Which response by the nurse is best?

This is a result of the treatments you are undergoing

The parents sit at the bedside and discuses a bicycle accident involving their oldest child who was riding a bicycle and accidentally hit the school age sibling, who experienced a a concussion. Which statement made by a parent validates the nursing diagnosis of dysfunctional family process?

This would not have happened if you had not stopped at the bar on the way home

The nurse develops a plan of care for a client diagnosed with dementia. Which intervention is most important for the nurse to include in the plan of care?

Use simple, short phrases when speaking with the client

When intervening with a client who is in a state of crisis, which statement by the nurse is most effective?

What have you done before when you felt this anxious?

A client scheduled for a CT scan says to the nurse, "The health care provider has me sign a form for the scan. I thought I understood what was said, but now I'm not so sure." Which is the best response by the nurse?

What is it that you are not sure you understand?

The nurse assesses a client newly admitted to a mental health unit with a history of hallucinations. The client points to a pair of slippers on the floor and informs the nurse that "there is a rat on the floor" which response is appropriate when assessing this client?

When did you being to see a rat? How does seeing the rat make your feel? Do you believe the rat is real?

A young adult client diagnosed with depression has a prescription for duloxetine. The client has not showered or eaten in days. Which response by the nurse to the client is appropriate?

When did you last take your prescribed medication? Do you have thoughts of harming yourself?

The nurse conducts an educational session for a group of clients at a mental health counseling center. Which client statement indicates the need for immediate intervention?

When my wife doesnt have dinner on the table by 5:30, I yell and scream at her.

The pediatric nurse discovers a clients parents crying at the bedside during morning rounds. Which response by the nurse is best?

You appear to be upset. How are you feeling right now?

An adolescent client asks the school nurse what to do when the parent has a panic attack during any attempt to leave the house. Which response will the nurse provide?

You are concerned for your parent, but more help is needed than you are able to provide

The nurse in the ambulatory care clinic prepares to perform a venipuncture on a client diagnosed with Crohn disease. The client suddenly becomes upset and asks, "what are you really going to be injecting into my veins?" Which is the best responses by the nurse?

You sound frightened. What are your specific concerns?

The nurse on the psychiatric unit overhears one client yelling at another, "You are always borrowing my things. Stay out of my way!" which response is best by the nurse?

You sound very angry with the other client.

A client in the long term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?

Your room is on the first floor by the elevator doors