NCLEX Review - Physiological Integrity (PART 1)

A nurse is assessing a client with depression who is at risk for suicide. The nurse would be concerned about the risk for suicide if the client made which of the following statements?

"God has called on me to come to him. He commands me to jump off the bridge tomorrow."

On the second day of hospitalization, a depressed client comes to the dayroom dressed neatly in slacks and a blouse, with hair combed back in a ponytail. The nurse should make which of the following statements to the client?

"I notice that you are dressed and that your hair is combed."

A person with posttraumatic stress disorder who has succeeded in focusing the trauma into a healthy perspective might make which of the following statements?

"It was bad luck. I was in the wrong place at the wrong time."

A nurse is interviewing the parents of a newborn infant who has spina bifida (myelomeningocele). Which of the following statements by a parent indicated a need to discuss coping issues?

"Should we tell our friends about the baby?"

A school nurse is teaching a class of high school students about the risk of sexually transmitted infections (STIs). What opening statement will best encourage participation within the group?

"The topic today is very personal. For this reason, anything shared with the group will remain confidential."

A nurse is monitoring a client for complications following thyroidectomy. The nurse notes that the client's voice is very hoarse, and the client is concerned about the hoarseness and asks the nurse about it. The nurse should make which of the following responses to alleviate the client's concern?

"This problem is temporary and will probably subside in a few days."

A stillborn was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse would further assist the family members in their initial period of grief?

"What did you name your baby?"

A nurse is caring for a depressed adult client who says to the nurse, "What do you thing I should do about my home? My son thinks I should sell it and move into something smaller now that I'm alone." Which of the following responses by the nurse is therapeutic?

"What would you like to do? Do you feel you'd be happier in a smaller place? As your depression lifts, you'll be able to decide what is best for you."

The client with obesity says to the clinic nurse, "I'm not sure that attending my Weight Watchers support group is the best thing for me to do." The nurse should make which of the following responses to the client?

"You have concerns about attending the Weight Watchers support group?"

A female prison client, who killed her abusive husband by shooting him six times, is eligible for parole and asks the nurse, "Do you think I have a chance of being paroled?" Which nursing response is a therapeutic response?

"You have promises of obtaining employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion."

A nurse is assigned to care for a client with paranoid personality disorder who is experiencing difficulty with diversional activity. The nurse plans care, knowing that which of the following activities is appropriate for this client?

A crossword puzzle

A client is receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the home care nurse that his urine has turned a darker color since he began to take this medication. The client wants to discontinue its use. The nurse interprets these concerns as which of the following?

A harmless side effect of the medication

After 6 weeks of therapy with an antipsychotic medication, the client returns to the heath care clinic for follow-up. The nurse documents a therapeutic response when which of the following is noted?

A well-groomed and neat appearance

An adolescent with juvenile idiopathic arthritis is being admitted to the hospital. The nurse should plan which of the following actions for initial intervention?

Access the adolescent's perception of the chronic illness

A client admitted to the hospital with Laennec cirrhosis is ready for discharge and expresses the motivation to prevent this condition from worsening. The nurse should inform the client about which of the following resources to assist the client?

Alcoholics Anonymous

When assisting a client who had a brain attack (stroke) to eat, the nurse can promote independence by taking which of the following actions?

Allow the client to participate as much as possible in eating

A client has prescriptions for an intravenous (IV) infusion to be started, blood to be drawn, and surgical skin preparation before surgery for a right below-the-knee amputation. Which priority concern does the nurse consider in providing preoperative care?

Anxiety because of the need for preoperative therapies

A child with croup is admitted to the hospital, and the physician prescribes a cool-mist tent. The child is fearful and crying. Which of the following nursing interventions is appropriate.

Ask the mother to bring the child's favorite toy from home

A nurse is developing a plan of care for a client experiencing difficulty with grieving. The priority in planning care for the client is which of the following?

Assessing the risk for violence toward self and others

A psychiatric nurse who is a member of a mobile crisis team is called to respond to a person who us threatening to jump off a bridge in a suicide attempt. On arrival at the site, which of the following nursing actions should the nurse immediately take?

Attempt to communicate with the client and try to develop a therapeutic relationship

A hospice nurse visits a client dying of ovarian cancer. During the visit the client expresses, "If i can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing?

Bargaining

A nurse is developing a plan of care for a client who is depressed. Which therapeutic nursing intervention should be included in the plan of care for this client?

Be matter-of-fact, displaying a hopeful but not overly cheerful attitude

A client with an anxiety disorder is also diagnosed with an acute inferior myocardial infarction and is placed on bed rest. The nurse includes measures in the plan of care to avoid which of the following potential complications related to bed rest?

Constipation

Which of the following actions must be taken for a client receiving tranylcypromine (Parnate) and sertraline (Zoloft) concurrently?

Consult with the physician and instruct the client to discontinue the sertraline for 2 weeks before starting the tranylcypromine

Which clinical manifestation would a nurse assess for when caring for a schizophrenic client who has a disintegrated sense of self?

Depersonalization

A client with a personality disorder will begin recreational therapy as a component of the treatment plan. The nurse provides information to the client regarding the therapy, knowing that this modality is helpful for clients who show which of the following characteristics?

Difficulty socializing

A nurse notes that a client with acquired immunodeficiency syndrome appears anxious and is reluctant to ask questions. Which of the following actions does the nurse take first to best deal with these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis

A nurse is collecting data from a client what has recently started on an antipsychotic medication. The nurse assesses the client for which common side effect of antipsychotics?

Dry mouth

A family of a client with Parkinson disease tells the nurse that the client is having difficulty adjusting to the disorder and that they do not know what to do to help. The nurse advises the family that which of the following is most therapeutic in assisting the client to cope with the disease?

Encourage and praise client efforts to exercise and perform activities of daily living (ADLs)

A hospitalized client with a diagnosis of delirium becomes disoriented and confused in her room at night. The nurse should take which action to assist in reducing the disorientation and confusion?

Ensure a low-stimulating environment at nighttime

The priority nursing action when caring for an older client who is a victim of physical abuse is which of the following?

Ensure that the client is safe

A nurse is planning care for a client with an obsessive-compulsive-disorder. The nurse assigns initial priority to which of the following nursing interventions?

Establishing a trusting nurse-client relationship

A female client with anorexia nervosa is a member of a predischarge support group. The client verbalized that she would like to buy some new clothes but that her finances were limited. Subsequently, group members brought some used clothes to the client to replace her old clothes. The client believed that the new clothes were much too tight and reduced her calorie intake to 800 calories daily. The nurse analyzes this behavior as:

Evidence of the client's disturbed and distorted body image

A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. the nurse should take which initial action?

Examine and treat the wound sites

A nurse is caring for a client with cardiomyopathy who is scheduled for a heart transplant. The nurse best meets the psychosocial needs of the client by taking which of the following actions?

Exploring with the client the meaning of the surgery

A client is diagnosed with terminal carcinoma of the lung, and the nurse is assisting the client to plan for end-of-life issues. The appropriate nursing intervention is to assist the client to take which of the following actions?

Gain control over the end-of-life issues through creation of advance directives

A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff believes that the client is very discouraged about her condition. It is important for the nurse to include which of the following information in discussions with the client?

Generally most people recover from this condition

A nurse is caring for a 7-year-old child with glomerulonephritis and discusses the plan of care with the parents who are upset about the diagnosis. The nurse interprets that the parents' reaction may be associated with which common initial reaction to the diagnosis of glomerulonephritis?

Guilt that they did not seek treatment more quickly

A nurse is performing an assessment on a preschool client. To facilitate the cooperation of the child, the nurse should:

Have the child pretend to be a nurse

A nurse assigned to care for a postpartum client plans to promote parent-infant bonding by encouraging the parents to take which of the following actions?

Hold and cuddle the infant closely

A client with a diagnosis of depression says to the nurse, "I always make mistakes. I never do anything right!" The best nursing action is to provide which of the following responses?

Identify recent client accomplishments that demonstrate skills and ability

A nurse working with a chronically mentally ill client can be successful in dealing with a client crisis by taking which of the following actions?

Identifying strengths and the healthy aspects of functioning that may compensate for the weaknesses

Which of the following behaviors would indicate to a nurse that an adolescent has not successfully completed the age-appropriate developmental task according to Erik Erikson theory?

Is rebellious and regresses to child-play behaviors

A nurse is planning stress management strategies for the client with irritable bowel syndrome. Which of the following suggestions should the nurse give to the client?

Learn measures such as biofeedback or progressive relaxation

A client with severe psoriasis is experiencing chronic low self-esteem. The nurse should use which of the following therapeutic strategies when working with the client?

Listening attentively

A mother of a toddler who is hospitalized with mild dehydration must leave her child to go to work. Which behavior would the nurse expect to observe in the toddler immediately after the mother's departure?

Loudly crying and kicking both legs

A nurse is caring for a client who verbalizes a need to increase her self-esteem. To aid the client in achieving her goal, the nursing care plan should include which of the following actions?

Maintain a well-groomed appearance

A nurse is caring for a client who is expecting psychomotor agitation. Which of the following activities would be appropriate for the nurse to plan for the client?

Playing Ping-Pong

A client with nephrotic syndrome states to the nurse: "Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do, if I can never get rid of this kidney problem anyway!" The nurse should address which of the following potential client problems?

Powerlessness

After being on bed rest in a private room for 1 week, the client exhibits periods of confusion. The physician writes a prescription to start progressive crutch walking as tolerated. Which nursing intervention would decrease the client's confusion?

Progressive ambulation in the hall three times a day

A nurse is assigned to the care of a client who is dying. Which of the following nursing interventions would be the least helpful to this client?

Provide extremely thorough answers to each question asked by the client or family

A client has just experienced a precipitate delivery. The nurse notes that the mother is lying quietly in bed and is avoiding physical contact with the newborn infant. Which of the following actions is appropriate for the nurse to take?

Provide support to the mother

A nurse is caring for a child with osteosarcoma after amputation of the lower left limb. The child is continually complaining of aching and cramping in the missing limb. The initial nursing action is which of the following?

Reassure the child that this is a temporary condition

A client has undergone below the knee amputation (BKA). The nurse determines that the client is having the most difficulty adjusting to the loss of the limb if which of the following behaviors are observed?

Refuses to look at the dressing

When performing an admission assessment for a child, the nurse suspects physical abuse. The appropriate nursing action is which of the following?

Report the case to legal authorities

A client is hospitalized with a diagnosis of severe depression. The client is withdrawn and exhibits poor motivation and concentration. The nurse plans to involve the client in which of following activities at this time?

Simple two-person card games

A nurse is caring for an anxious client who just had a chest tube inserted and an occlusive dressing placed over the insertion site. Which intervention would have the greatest overall immediate benefit to assist the client?

Staying with the client

Which emotional response related to chronic respiratory disease requires immediate nursing intervention?

Suicidal ideation

A psychiatric nurse is working with victims and families involved in an explosion at a local industry. The important nursing intervention in the immediate post-disaster period is which of the following?

Talk to people who are waiting to receive assistance

A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this employee by taking which of the following actions?

Telling a friend that this employee hates her or him

a mother of a 9-year-old child in whom diabetes mellitus is newly diagnosed is very concerned about the child going to school and participating in social events. The nurse develops a plan of care with which of the following goals?

The child and family will integrate diabetes care into patterns of daily living

A nurse is monitoring a depressed female adolescent who may be suicidal. Which behavior observed by the nurse indicated that the clients is at high risk for suicide?

The client gives her special book of poems to another client

A client who is paraplegic after a recent spinal cord injury intermittently refuses care by the nurse and becomes angry and belligerent at times. The nurse makes which of the following interpretations of the client's behavior?

The client is acting out feelings of anger about the accident and injury

Which goal would be appropriate for the client in the emergency department being treated for rape-trauma syndrome?

The client will begin the healthy grief process

A nurse is analyzing the assessment date obtained from a client with physical injuries and suspected family-related violence. In analyzing the data, the nurse should first consider:

The client's vital signs

A family is experiencing the impending death of their youngest child who is 4 years old. The siblings are ages 6, 9, and 10 years of age. The nurse develops which appropriate goal for the family?

The parents and siblings will spend private family time together with the dying child

A 9-month-old infant is admitted to a pediatric unit with a diagnosis of dehydration and malnutrition and suspected failure to thrive. Child neglect is suspected. Which of the following would be important for the nurse to observe when the parents visit the infant?

The parents' level of concern about the child

When collecting data during the psychosocial assessment of a human immunodeficiency virus infected client, the nurse should first determine which of the following?

The presence of any concerns or fears

A nurse is conducting a group therapy session, and a female client with a manic disorder is monopolizing the group. The nurse should tell the client which of the following?

To stop talking and try to listen to others

An older client who has been in traction for several days is becoming disoriented. The nurse implements which appropriate intervention?

Uses environmental cues such as calendars and clocks along with gentle corrective reminders to reorient the client

A client has a diagnosis of dependent personality disorder. Of the following goal statements, which is appropriate for the nurse to document?

Uses the problem-solving process effectively

A male client is diagnosed as a power rapist. The nurse plans interventions for the client, keeping in mind that a power rapist is one who acts in which of the following ways?

Wants to place a woman in a helpless controlled situation in which she cannot resist or refuse him

A nurse is planning care for a client who is experiencing psychomotor agitation. Which of the following activities would be appropriate for the nurse to plan for the client?

Working with clay

A nurse is assigned to care for a client admitted to the mental health unit with a diagnosis of mania. Which activity should the nurse provide for the client initially?

Writing

A nurse suspects that a female client is a victim of physical abuse. Which statement encourages the client to confide in the nurse?

"I sometimes see women who have been hurt by their boyfriends or husbands. Did anyone hit you?"

A client on the psychiatric unit is displaying manipulative behavior. The nurse should use which interventions in working with this client? (Separate responses with commas) 1: Identifying the manipulative behaviors exhibited by the client. 2: Communicating to the client the behaviors that are expected. 3: Describing clearly the consequences of not staying within identified limits related to behaviors. 4: Making accusations regarding the client's behaviors. 5: Being prepared to argue with the client to ensure that views of a situation are shared.

1, 2, 3

A family is trying to communicate with a brain attack (stroke) client with aphasia, and the nurse provides a list of interventions to the family to promote effective communication. Which interventions should the nurse place on the list? (Separate responses with commas) 1: Speak to the client at a slow rate. 2: Look directly at the client which listening. 3: Allow sufficient time for the client to respond. 4: Complete the sentences that the client cannot finish. 5: Raise the volume of the voice when talking to the client. 6: Allow family members to give all the responses for the client while someone is asking the client questions.

1, 2, 3

The nurse prepares to implement suicide precautions for a suicidal client. Select the nursing interventions with regard to these precautions. (Separate responses with commas) 1: Maintain arm's length distance with the client at all times. 2: Ensure that meal trays contain no glass or metal silverware. 3: Carefully watch the client swallow each dose of medication. 4: Conduct one-on-one nursing observation interaction 24 hours a day. 5: Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. 6: Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.

1, 2, 3, 4, 5

A community health nurse is conducting an awareness workshop on adolescent suicide. Which of the following should the nurse discuss as risk factors? (Separate responses with commas) 1: Family violence 2: Poor impulse control 3: Use of alcohol or drugs 4: Strong peer relationships 5: Family history of depression 6: Adequate school performance

1, 2, 3, 5

A nurse is attempting to deescalate aggressive behavior exhibited by a client with schizophrenia. Which actions should the nurse take? (Separate responses with commas) 1: Be assertive with the client. 2: Negotiate options with the client. 3: Demonstrate control and aggressiveness with the client. 4: Give the client lengthy instructions to distract the client. 5: Persuade the client to move to another area of the nursing unit. 6: Stand close to the client, and tell the client that the behavior is unacceptable.

1, 2, 5

A registered nurse is supervising a licensed practical nurse that is providing care to a client with end-stage heart failure. The client is withdrawn, reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement(s) by the licensed practical nurse to the client are therapeutic? (Separate responses with commas) 1: "You are very quiet today." 2: "What are your feelings right now?" 3: "Why don't you feel like getting up?" 4: "You have the best physician. Everything will be fine." 5: "Tell me more about your difficulty with sleeping at night."

1, 2, 5

A nurse manager is conducting an educational session for nursing staff of seclusion for clients with a mental health disorder. Under which circumstances is seclusion contraindicated? (Separate responses with commas) 1: The client has severe dementia. 2: The client requests to be secluded. 3: The client experiences a severe drug overdose. 4: The client presents a clear and present danger to self or others. 5: The client has been legally detained for involuntary treatment and is thought to pose an escape risk. 6: The client has an unstable mental health disorder and nursing staff needs to attend a monthly staff meeting.

1, 3, 6

A client was originally prescribed oral sertraline (Zoloft) 25 mg daily for depression. The dose has gradually increased in an effort to control the symptoms. The current dose is 75 mg daily. The medication label reads 25 mg/tablet. To receive the correct dose, the nurse instructs the client to take how many tablets once daily?

3 tablets

A registered nurse prepares to care for a client with paranoia who experiences disturbed thought processes. Which interventions should the nurse carry out in the care of the client? (Separate responses with commas) 1: Sit with the client and hold the client's hand. 2: Use a warm approach when working with the client. 3: Use simple and clear language when speaking with the client. 4: Diffuse angry and hostile verbal attacks with a nondefensive stand. 5: Use a nonjudgmental attitude when working with the client.

3, 4, 5

When administering a liquid medication to an uncooperative toddler, a nurse should implement which of the following strategies?

Allow the parents to remain in the room

A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares feelings of social isolation with the nurse. Which strategy does the nurse suggest to the client to decrease these feelings?

Contacting any of the local support groups for clients with AIDS

A nurse is assigned to care for a client who is Asian (Chinese). The nurse enters the room and, following a greeting and introduction to the client, begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which of the following actions?

Continue with the discussion

A young male client with Hodgkin disease is going to receive radiation therapy. The nurse should include which of the following psychosocial interventions in the plan of care for the client?

Discussing sperm banking with the client

A client hospitalized with hepatitis complains of fatigue and feelings of depression. The nurse should plan with of the following strategies to help the client cope effectively during recuperation?

Encourage restful diversional activities per client preference

A client receives a diagnosis of late-stage human immunodeficiency virus infection, and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to:

Encourage the client and family to discuss their feelings about the disease

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measure to alleviate the couple's distress?

Engage the spouse in providing comfort

A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first:

Inspect the client for injuries resulting from the incident and initiante appropriate treatment

A woman comes into the emergency department in a severe state of anxiety after witnessing a fatal car accident. Which of the following is appropriate nursing intervention?

Remain with the client

A nurse is assigned to care for a client diagnosed with catatonic stupor. On entering the client's room, the nurse finds the client lying on the bed with the body pulled into a fetal position. The appropriate nursing action is which of the following?

Sit beside the client in silence

A mental health nurse reviews the activity schedule for the day and determines that the best activity that a manic client could participate in is which of the following?

Tetherball

A nurse observes that a client who had a brain attack (stroke) 2 weeks ago is using foul language when speaking with his wife. The nurse's interpretation of the situation is which of the following?

The client is frustrated

A client with quadriplegia complains bitterly about the nurse's slow response to the call bell and the rigidity of the therapy schedule. Which interpretation of this behavior serves as a basis for planning nursing care?

The client is reacting to the loss of control

A female client who has been raped arrives at the emergency department. Which client statement would be important for a nurse to consider when planning the immediate care for the client?

The victim states the rapist knows where she lives and said he will kill her if she tells anyone about the rape

A nurse has taught a family to communicate more effectively with a hearing-impaired client. Which behavior by the family, if observed, confirms learning?

Using appropriate hand motions with communication

When assessing a client's psychosocial adjustment to a newly applied body cast, the nurse should collect data regarding which of the following?

Usual coping techniques