NCLEX Review

A client with schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective is for hallucinating clients to: a. take an as-needed dose of psychotropic medication whenever they hear voices. b. go to their room until they can't hear the voices. c. sing loudly to drown out the voices and provide a distraction for themselves. d. practice saying, "Go away" or "Stop" when they hear voices.

Correct Answer: d Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.

During a unit meeting attended by clients and staff, several clients are criticizing their primary nurses. These clients have also been intimidating two other clients who have recently been admitted to the unit, and now the new clients have stopped sharing their opinions during the meeting. What is the first action for the nurse to take? a. Help the new clients express the reasons they have stopped sharing their ideas. b. Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing. c. Give the clients who are publicly criticizing the nurses a verbal warning that this behavior is not acceptable. d. Use the next unit meeting to discuss respect and the importance of collaboration with the treatment team.

b. Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing. Recognizing that the clients are part of the solution to the issues they are presenting demonstrates a client-centered approach to care. Having the new clients challenge the behaviors of other clients does not facilitate the development of a therapeutic milieu. Warning clients that behaviors are unacceptable reinforces a sense of client powerlessness and does not build a therapeutic relationship. Discussing respect and collaboration would happen after the criticisms have been acknowledged and the clients have been asked for their opinions.

For the client receiving outpatient treatment for depression and suicidal ideation, what is the correct amount of imipramine to have at one time? a. a 14-day supply b. a 21-day supply c. a 7-day supply d. a 30-day supply

c. 7-day supply Because the client has a history of recurring depression and suicidal ideation, the nurse would give the client a 7-day supply of imipramine to prevent possible overdose. Giving the client a 14-, 21-, or 30-day supply of medication would provide the client with enough medication to complete a suicide attempt. Tricyclic antidepressants are associated with a higher rate of death than are selective serotonin reuptake inhibitors.

The nurse should instruct the client who has had nasal surgery to implement which nasal care measure after the nasal packing is removed? a. Irrigate the nares with normal saline solution daily. b. Remove old blood from inside the nares with cotton-tipped applicators. c. Lubricate the membranes with a water-soluble lubricant. d. Avoid cleaning the nares for at least 2 days.

c. Lubricate the membranes with a water-soluble lubricant. A water-soluble lubricant offsets dryness and enhances comfort during healing. The lubricant also prevents secretions from drying and crusting in the nose. Irrigating the nares is not recommended as it may initiate bleeding by dislodging clots. The client should be cautioned not to disturb clots because bleeding may occur. Nares may be gently cleaned after removal of the packing.

A nurse is caring for a client who reports dyspnea while resting as 5 on a scale of 1-10, has a respiratory rate of 26 breaths/min, and exhibits an oxygen saturation of 96% on room air. Based upon these findings, what outcome should the nurse incorporate in the plan of care? a. The client has a respiratory rate between 12-20 breaths/min and no adventitious breath sounds. b. The client's oxygen saturation remains above 92% and respiratory rate under 20 breaths/min. c. The client is able to perform activities of daily living without tachypnea or dyspnea above level 2. d. The client's resting dyspnea is under level 4, and respiratory rate is 12-20 breaths/min.

d. The client's resting dyspnea is under level 4, and respiratory rate is 12-20 breaths/min. The nurse plans outcomes that are specific and measurable where possible and that reflect an improvement in the condition that is achievable in the given time frame. Since the reported problems are "dyspnea while resting at 5 on a 10-point scale" and an elevated respiratory rate, the outcome that identifies a lower dyspnea score and reduced rate is appropriate. In this case, there is no mention of adventitious breath sounds being present, so they should not be identified in the outcomes. The client's dyspnea was measured at rest, so it should not be compared to dyspnea with activity, which could have a different rating. The initial room air oxygen saturation is 96%, so an outcome of 92% does not reflect stability or improvement in the client's condition.

A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings? A. serum calcium level of 5 mg/dL(1.25 mmol/L) B. platelet count of 80 x 103/mm3 (80 X 109/L) C. partial thromboplastin time of 38 seconds D. fibrinogen level of 75 mg/dL (2.21 µmol/L)

B. platelet count of 80 x 103/mm3 (80 X 109/L) In leukemia, megakaryocytes, from which platelets are derived, are decreased. Normal platelet counts range from 150 to 300 × 103/mm3 (150 to 300 X 109/L). A platelet count of 80 × 103/mm3(80 X 109/L) is low, predisposing the child to bruising and bleeding easily. Although the serum calcium level is decreased, low serum calcium levels are not related to bleeding and bruising in a child with leukemia or any aspect of leukemia.Normal fibrinogen levels range from 200 to 400 mg/dL (5.9 to 11.8 µmol/L). However, insufficient fibrinogen concentration is not related to bleeding and bruising in a child with leukemia or any aspect of leukemia.Partial thromboplastin time (PTT), a measurement of clotting factors (except factor XIII), normally ranges from 25 to 40 seconds. The child's PTT is within the normal range.

The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate? a. "Infants have a fat pad below the arch, making it look like flat feet when they are not." b. "Nightly exercises will help make the arches supple." c. "Corrective shoes will strengthen the arches of the feet." d. "Flat feet cause other orthopedic problems in infants."

a. "Infants have a fat pad below the arch, making it look like flat feet when they are not." Infants have a fat pad below the arch, giving the appearance of flat feet. Exercises will not correct flat feet. Flat feet cause no other orthopedic problems in infants. Corrective shoes will have no effect on strengthening the arches of the child's feet.

A client is prescribed exenatide. What should the nurse instruct the client to do? Select all that apply. a. Administer the drug within 60 minutes before morning and evening meals. b. Take the dose of exenatide as soon as the client remembers a dose has been missed. c. Understand that there is a low incidence of hypoglycemia when exenatide is taken with insulin. d. Review the one-time set-up for each new pen. e. Inject in the thigh, abdomen, or upper arm.

a. Administer the drug within 60 minutes before morning and evening meals. d. Review the one-time set-up for each new pen. e. Inject in the thigh, abdomen, or upper arm.

The client with acute mania is prescribed 600 mg of lithium PO three times per day. The health care provider (HCP) also prescribes 5 mg of haloperidol PO at bedtime. Which action should the nurse take? a. Administer the medication as prescribed. b. Administer the haloperidol but not the lithium. c. Question the HCP about the prescription. d. Consult with the nursing supervisor before administering the medications.

a. Administer the medication as prescribed. The nurse should administer the medication as prescribed. Lithium has a clinical response lag time of 1 to 2 weeks. Haloperidol is prescribed temporarily to produce a neuroleptic effect until the lithium starts to produce a clinical response. Haldol is usually discontinued when the lithium starts to take effect.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply. a. vital signs b. gait c. skin color d. peripheral pulses e. urine output f. nutrition

a. vital signs c. skin color e. urine output d. peripheral pulses Shock is a medical emergency in which the organs and tissues of the body are not receiving adequate blood flow. Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys and peripheral pulses all provide assessment data relating blood volume and circulation. Nutrition and gait are not related to blood circulation.

A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse? a. "We will prepare your child to have spinal fluid withdrawn and analyzed." b. "The best way to diagnose seizures is through a computed tomography (CT) scan." c. "It's important to confirm a previous history of seizures for the child." d. "The child will need to have skull X-rays performed to verify the seizures."

b. "The best way to diagnose seizures is through a computed tomography (CT) scan." CT scans provide the most benefit of the list provided in determining irregular brainwave activity. None of the other options would be used to measure brain wave activity.

When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task? a. initiative b. autonomy c. trust d. industry

b. autonomy The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? a. respiratory alkalosis b. metabolic alkalosis c. respiratory acidosis d. metabolic acidosis

b. metabolic alkalosis. Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate increases, and the pH becomes more alkaline.Respiratory alkalosis is caused by conditions such as hyperventilation that result in loss of partial pressure of arterial carbon dioxide (PaCO2).Respiratory acidosis is caused by conditions such as inadequate ventilation that result in excessive retention of PaCO2.Metabolic acidosis results from the loss of large amounts of bicarbonate, such as with severe diarrhea.

Which finding alerts the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? a. sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours b. restlessness and shortness of breath c. urine output of 180 mL during the past 3 hours d. increased blood pressure and decreased pulse and respiratory rates

b. restlessness and shortness of breath Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 mL/h is normal in the early postoperative period. Urine output of 180 mL over the past 3 hours indicates normal kidney perfusion.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which of the following medications does the nurse anticipate the physician will order for the client's migraines? a. captopril b. verapamil c. metoprolol d. amiodarone

b. verapamil

A nurse is caring for a postsurgical client with two types of drains. Which activities can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Assess the drainage of an open drainage system, such as a Penrose drain. b. Document drain site and surrounding tissue status. c. Stabilize an open drainage system, such as a Penrose drain. d. Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. e. Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

d. Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. e. Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain. The nurse may delegate to the UAP emptying the closed drainage system and recording the output to the unlicensed assistive personnel. A closed drainage system, such as a Jackson-Pratt drain or Hemovac drain is anchored to the skin with one or more sutures. However, open-drainage systems, such as the Penrose drain, are not anchored to the skin. For this type of drain, it is important for the nurse to care for the drain so as to prevent inadvertent dislodgment. Assessing and documenting the drain site is a nursing responsibility.

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client? a. lidocaine b. dopamine c. insulin d. nitroprusside

d. Nitroprusside Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor

A health care provider has placed a stat order for a urine specimen for culture and sensitivity. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel? a. We need a stat urine culture on the client in room 101. b. Please get the urine for culture for the client in room 101. c. A stat urine has been ordered for the client in room 101. Would you get it? d. We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab.

d. We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab. This option not only delegates the task but also provides a checkpoint. To effectively delegate, you need to follow up on what someone else is doing. The other options don't provide for feedback, which is essential for communication and delegation.

A client with Alzheimer's disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which statement? a. "I've put special locks on all the doors that Dad will not be able to unlock." b. "I've taken the knobs off of the stove so he won't be able to turn it on." c. "Dad said that what he missed most while he was here was using his aftershave." d. "Dad will be in a bedroom that has nothing for him to trip over getting to the bathroom."

c. "Dad said that what he missed most while he was here was using his aftershave." The client with Alzheimer's dementia should not have access to toiletries that could be swallowed (such as aftershave) unless closely supervised. Putting special locks on all the doors is appropriate to prevent wandering, thus maintaining the client's safety. Placing the client in a room that has nothing to trip over is appropriate to reduce the client's risk of falling. Taking the knobs off of the stove is appropriate to prevent possible burns.

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? a. within 2 weeks b. after induction therapy is completed c. within 1 month d. within hours

a. within 2 weeks Bone marrow depression is most likely to occur 10 days after methotrexate is administered.