NCLEX questions

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?

Observe for excessive exercise

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? (Select all that apply.) 1. Hallucinations 2. Anhedonia 3. Delusions 4. Neologismd 5. Flat affect

1. Hallucinations 3. Delusions 4. Neologisms

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?

Perhaps you could just enjoy the music with singing

The nurse is admitting a victim abuse client to the mental health unit with a diagnosis of severe anxiety. The nurse notes which signs/symptoms that indicate it is difficult for the victim to talk about the situation? (Select all that apply.) 1. Hesitation 2. Lack of eye contact 3. Speaking crude words 4. Using assertive communication 5. Respecting one's personal space 6. Using vague statements such as Its been rough lately

1. Hesitation 2. Lack of eye contact 6. Using vague statement such as Its been rough lately

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? (Select all that apply.) 1. Making nutritious snacks availabel anytime 2. Providing meals on an isolation tray that contains plastic utensils 3. Removing unit privileges based on her willingness to eat appropriately 4. Ensuring that her diet consists of bland easy to digest foods and beverages 5. Explaining that while being thin is desirable she needs to eat to be healthy

1. Making nutritious snacks available anytime 2. Providing meals on an isolation tray that contain plastic utensils 4. Ensuring that her diet consists of bland easy to digest food and beverages

The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? (Select all that apply.) 1. Paralysis 2. Skin rash 3. Blindness 4. Parasthesia 5. Movement disorder 6. Fractures noted on x-rays

1. Paralysis 3. Blindness 4. Parasthesia 5. Movement disorder

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? (Select all that apply.) 1. Client had not bathed in 2 days 2. Client threatened to commit suicide 3. Client threatened to kidnap his spouse 4. Client quit taking antipsychotic medications 4 days ago 5. Client wrote the Declaration of Independence in chalk on the sidewalk

2. Client threatened to commit suicide 3. Client threatened to kidnap his spouse

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention?

Constant physical activity and poor oral intake

The nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client?

Slowed walking and talking

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation would the nurse make of this behavior?

The client is displaying typical behaviors that can occur during termination

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group?

The leader of this self-help group is the nurse or psychiatrist

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition

A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make?

It seems that you needed help to seperate from your family. Do you feel you are ready to have a baby with Johnny

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? (Select all that apply.) 1. Reinforce the client's problem solving abilities 2. Focus attention on the client's physical complaints 3. Voice doubt in the reality of the client's physical symptoms 4. Assess "secondary gains" that the somatic illness provides the client 5. Only spend time with the client when physical illness is not discussed

1. Reinforce the client's problem solving abilities 4. Assess "secondary gains" that the somatic illness provides the client

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions would the nurse use in providing care for the client? *Select all that apply.) 1. Do not allow the client to express negative thoughts 2. Immerse the client with all the details of past events 3. Request that the client perfrom undemanding self-care tasks 4. Reinforce teaching the client techniques to maintain present reality 5. Assist the client to reestanlish relationships with significant others

3. Request that the client perform undemanding self-care tasks 4. Reinforce teaching the client techniques to maintain present reality 5. Assist client to reestablish relationships with significant others

The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client?

writing

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?

Do you recall needing to be hospitalized because you stopped your medication

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?

Examine and treat the wound sites

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse would make which therapeutic response to the client?

It must be frightening to you, Has someone made you feel that your food is poisoned?

The nurse is providing care for 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?

I can not promise to keep the secret

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment would include which intervention?

The client shampoos and dries the hair, freeing it of all hair spray and creams

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?

The client verbalizes stages of grief and plans to attend a community grief group

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance

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

Use a night light and turn off the television

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? (Select all that apply.) 1. Outlandish behaviors 2. Takes a shower every other day 3. Purposeless arousal and movement 4. Occasional episodes of mild depression 5. Grandiose delusions of being King Arthur 6. Incessant talking that includes sexual innuendos

1. Outlandish behaviors 3. Purposeless arousal and movement 5. Grandiose delusions of being King Arthur 6. Incessant talking that includes sexual innuendos