Bathke's NCLEX questions from Billings

PHARM 19 CN: Psychosocial adaptation; CL: Synthesize The client is taking sertraline (Zoloft), 50 mg q a.m. The nurse includes which of the following in the teaching plan about Zoloft? Select all that apply. - Zoloft may cause erectile and ejaculatory dysfunction in some men. - It may be 1 to 2 weeks after starting Zoloft before the client begins to feel better physically. - Zoloft causes light-headedness or dizziness when rising. - Zoloft increases the appetite and causes weight gain. - Zoloft can cause agranulocytosis. - Zoloft may cause seizures.

ANSWER= A,B,C. RATIONALE: Zoloft may cause erectile and ejaculatory dysfunction. A decrease in dosage may decrease these symptoms. Physical benefits typically occur in 1 to 2 weeks. Improvement in thinking and mood may take longer. Zoloft can cause orthostatic hypotension.

COMMUNICATION 15 GERO CN: Psychosocial adaptation; CL: Evaluate A 62-year-old client reports being tired all the time, having trouble sleeping, and having trouble thinking. The nurse should: - Inform the client about the normal aging process. - Further assess the client's mental status and health history. - Refer the client to a senior citizens' support group. - Advise the client to discontinue daytime napping.

ANSWER= B. RATIONALE: Fatigue, difficulty thinking, and sleep disturbances can signal depression or other medical problems. The nurse should explore the client's medical and psychosocial history and conduct a mental status examination to gather additional data before making recommendations.

Communication 10 CL: Evaluate After hearing a client with bulimia talk about her bizarre eating binges of raw pancake batter and bowls of whipped cream, the nurse feels disgusted and feels like telling her to "snap out of it." Which of the following would be the best action for the nurse at this time? - Share these feelings with the client, pointing out that the client's behavior alienates people. - Ask the client to talk more about her eating habits, trying to understand her underlying problem. - Suggest that another nurse work with the client because this relationship is no longer therapeutic. - Discuss these feelings with another nurse or colleague in an attempt to help to resolve them.

ANSWER= D. RATIONALE: The nurse is experiencing a countertransference reaction that can only be resolved by self-reflection and discussion with other professionals. Examining reactions, feelings, and behaviors helps the nurse interact more appropriately with clients.

PHARM 2 CN: Pharmacological and parenteral therapies; CL: Analyze Which of the following statements about clozapine (Clozaril) indicates that the client needs additional teaching? - "I need to have my blood checked once every 6 months while I'm taking this drug." - "I need to sit on the side of the bed for a while when I wake up in the morning." - "The sleepiness I feel will decrease as my body adjusts to clozapine." - "I need to call my doctor when I have a fever or sore throat."

ANSWER=A. RATIONALE: Agranulocytosis is a serious adverse effect of clozapine (Clozaril). Therefore, the client needs to have complete blood cell counts weekly to monitor for this possible serious decline in white blood cells (WBCs). After 6 months, the WBC count is monitored every other week.

EATING DISORDER 1 A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which of the following for the client? - Feelings of euphoria and gratification. - Feeling out of control and disgusted with self. - Leaving traces of food around to attract attention. - Eating increasing amounts of food for substantial weight gain.

ANSWER=B. RATIONALE: For the client with bulimia, binges involve a loss of control that results in thoughts of self-deprecation.

PHARM 1 & Schizo CN: Psychosocial adaptation; CL: Synthesize When caring for a client receiving haloperidol (Haldol), the nurse should assess for which of the following? - Orthostasis. - Extrapyramidal symptoms. - Hypersalivation. - Oversedation.

ANSWER=B. RATIONALE: Haloperidol (Haldol), a traditional antipsychotic drug, is associated with a high rate of extrapyramidal (EPS) adverse effects.

CRISIS INTERVENTION 2 CN: Psychosocial adaptation; The nurse answers a call on a telephone hotline from a man who was at the crisis center once in the past when he made a suicide threat. The client says, "Don't try to help me anymore. This is it. I've had enough and I have a gun in front of me now." Then he hangs up the telephone. Which of the following calls should the nurse make first? - Client, to make an attempt to calm him. - Police, to request their intervention. - Client's wife at work, to suggest she hurry home. - Neighbor, to request he go to the client's home immediately.

ANSWER=B. RATIONALE: The nurse's first responsibility when a client threatens suicide is to do whatever can be done most quickly to protect the client from himself. When the nurse is in a crisis center and the client is at home, it is best to call the police to intervene. They will be able to reach the client quickly and are experienced in handling such situations. It is appropriate to err on the side of safety rather than to assume that the client is not serious about a suicide threat.

SCHIZOPHRENIA 1 A client with chronic schizophrenia is admitted to the hospital on an emergency detention. The client states to the nurse, "I didn't do anything wrong. I was just carrying out the orders God gave me to paint an X on the door of all sinners." Several hours after being admitted, the client wants to leave the hospital. In addition to explaining that the staff is concerned about the client's health and safety, which of the following should the nurse tell the client? - "It will take about 24 hours to complete the evaluation." - "You must stay at least 2 days but then may be able to leave. - "The court has mandated that you undergo a 72-hour evaluation." - "The law requires you to stay here until you are well."

ANSWER=C. RATIONALE: Clients admitted on an emergency detention must remain hospitalized for the time allotted for the evaluation. In this case, the time is 72 hours. The 72 hours do not include weekends or holidays. If the treatment team completes the evaluation in less than the allotted time, they may decide to discharge the client or may institute further commitment procedures. Clients cannot sign themselves out of the hospital during this period. Family members also cannot authorize the client's release.

MILIEU, COMMUNICATION 7 & DEPRESSION 1 SUICIDE PD Which of the following outcomes are therapeutic and realistic when the nurse is planning care for a female client with major depression and borderline personality disorder who is hospitalized for self-mutilation and threats of suicide? - The client will stay in her room when overwhelmed by feelings. - The client will leave the group when angry. - The client will appropriately verbalize anger and sad feelings to the nurse. - The client will ask the nurse for a prescribed medication when feeling out of control.

ANSWER=C. RATIONALE: The client needs to ventilate and discuss feelings of anger and sadness with the nurse to decrease behaviors of self-harm. Other alternatives such as punching the pillow may be helpful to the client in expressing anger and rage. The nurse helps the client to develop safe methods of handling intense feelings.

PHARM 3 CN: Psychosocial adaptation; CL: Analyze When providing a therapeutic milieu for clients, which of the following would be most appropriate? - Using psychotropic drugs primarily. - Fostering dependent client behavior. - Promoting optimal functioning of an individual or group. - Meeting one's own needs while helping clients meet their needs.

ANSWER=C. RATIONALE: The milieu should provide an atmosphere that fosters growth, change, and self-responsibility. Staff interventions should also be flexible and open, and encourage clients to achieve optimal functioning.

DEPRESSION The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which of the following goals would be most appropriate for the nurse to include in the plan of care at this time? The client will: - Increase her self-esteem - Write her negative feelings in a daily journal. - Verbalize her work-related accomplishments. - Verbalize three things she likes about herself.

RATIONALE: D. Describing and verbalizing feelings are necessary and normal because the client has usually repressed or blocked feelings that are partly responsible for the client's pain. Expressing feelings is a prerequisite before the nurse can intervene in how the client thinks or behaves. Asking the client to identify only three qualities is not overwhelming.

ALZHEIMER'S Evaluate When asked how she cut her finger, a client with Alzheimer's disease says, "While cutting flowers in our garden." The client's husband later tells the nurse that they do not have a flower garden. The nurse interprets the client's statement as which of the following? - Displacement. - Confabulation. - Disorientation. - Flight of ideas

ANSWER = B. RATIONALE: Because the client has a cognitive disorder and no garden, the nurse interprets the client statement as confabulation (i.e., making up stories to fill in memory gaps).

COMMUNICATION 6 CN: Psychosocial adaptation; CL: Analyze A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When is he going to come get me out of here?" The nurse interprets the client's statements as indicative of which of the following? - Ambivalence. - Autistic thinking. - Associative looseness. - Auditory hallucinations.

ANSWER= A RATIONALE: Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation evidenced in one instance by the client stating she is going to divorce her husband then stating that she misses and loves him.

COMMUNICATION PATIENT RIGHTS LEGAL ISSUES Synthesize A client who has been staying at a local hotel for 3 days is brought to the mental health center by a police officer because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." The police can hold her for disturbing the peace but think she needs psychiatric evaluation. Which of the following factors would be most relevant to a decision about this client's disposition? - She seems able to care for herself. - She has no known family. - She is not known to the mental health center. - She has $500 in cash and wants to go back to the hotel.

ANSWER= A. RATIONALE: This client's ability to care for herself is most relevant to a decision about her disposition.

DEPRESSION 2 CN: Psychosocial adaptation; CL: Synthesize During the nurse's conversation with a depressed client, the client states, "I have no reason to be sad. I have a great job and a wonderful wife and family." Which of the following comments would be best for the nurse to make at this time? - "Why do you think you're depressed?" - "Think about how fortunate you are." - "You have many positive qualities." - "Depression can be caused by a chemical imbalance in the brain."

ANSWER= D. RATIONALE: The biological theory of depression suggests that an imbalance of the neurotransmitters serotonin, norepinephrine, and possibly dopamine causes endogenous depression (depression coming from within the person).

PHARM 4, DEPRESSION 3 CN: Pharmacological and parenteral therapies; CL: Create The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective? - "His depression is almost cured." - "He's intelligent and won't need to depend on a pill much longer." - "It's important for him to take his medication so that the depression will not return or get worse." - "It's important to watch for physical dependency on Zoloft."

ANSWER=C. RATIONALE: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms.

CRISIS INTERVENTION 1 CN: Psychosocial adaptation; Which of the following techniques would be least appropriate for the nurse to implement in crisis intervention? - Encouraging the client to ventilate feelings. - Including the client in finding solutions to the problem. - Using active and flexible approaches. - Attacking the client's maladaptive defenses.

ANSWER=D RATIONALE: D. Attacking the client's defenses decreases his ability to maintain self-esteem and ego integrity. Doing so would be the least appropriate action. Rather, the nurse should carefully encourage and teach adaptive behaviors.

BIPOLAR Which of the following indicates that a male client with bipolar disorder, manic phase, is nearing readiness for discharge? A. Sleeping 4 hours per night. B. Differentiating realistic self-image from grandiosity. C. Suddenly telephoning his wife and asking her for a divorce. D. Demonstrating a labile affect.

Answer = B RATIONALE: B. The client is approaching discharge when he is able to differentiate between a realistic self-image and grandiosity. A client with mania typically experiences a high regard for self or inflated self-image, seen as grandiosity. The ability to view one's self realistically demonstrates improvement.

Therapeutic relationship Which of the following client behaviors indicates the nurse-client relationship is in the working phase? - The client attempts to familiarize himself with the nurse. - The client makes an effort to describe his problems in detail. - The client tries to summarize his progress in the relationship. - The client starts to challenge the boundaries or outer limits of the relationship.

Answer = B. RATIONALE: B. This nurse-client relationship is most probably in the working phase. The client's effort to describe his problems to the nurse illustrates that the client has gone beyond testing and acquainting himself with a new relationship and is now working on his problems.

Abuse/Psychosocial adaptation; Which of the following statements about the initial care of a suspected abuse victim, when documented on the chart, would be helpful for others when caring for the client? - States that she is not employed outside the home. - Seems fearful to discuss how bruises on her body had been caused. - Asks that her husband not be called at work, stating that he is very busy. - Refuses a follow-up appointment, stating that she does not have time."

Answer = B. RATIONALE: Stating that a client seems fearful to discuss what caused the bruises on her body is most helpful. A victim of partner abuse tends to conceal her victimization because disclosure could be met with denial; minimization by her partner, friends, and relatives; and increased abuse by her partner.

Psychosocial adaptation; Which of the following indicate that a client who has been raped will have future adjustment problems and the need for additional counseling? - When she becomes upset when talking about the rape to anyone. - When she seeks support from formerly ignored relatives and friends. - When her parents show shame and suspicion about her part in the rape. - When her life becomes focused on helping other rape victims like herself

Answer = C. RATIONALE: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it.

Therapeutic relationship A client is admitted to the psychiatric unit with sleep disturbance, fatigue, feelings of uselessness, and inability to concentrate. On the day after an interview during which the client talked at length and tearfully about feeling useless and old, she failed to keep an appointment with the nurse. Which action would be best for the nurse to take? - Assume that the client had a good reason for not coming and let her make the next move. - Confront the client with her behavior and ask her to explain the reason for her absence. - Seek out the client at the end of the scheduled interview time and tell her she was missed today. - Arrange for another session with the client later the same day and say nothing about her absence.

Answer = C. RATIONALE: The responsibility for maintaining a relationship with a client rests with the nurse. If a client misses a scheduled interview, the nurse is assuming responsibility for the relationship by seeking her out at the end of the scheduled interview time and telling her she was missed.

Depression A nurse meets frequently with a depressed client. The client stays mostly in his room and speaks only when addressed, answering briefly and abruptly while keeping his eyes on the floor. Initially, the nurse should focus on the client's ability to do which of the following? - Make decisions. - Relate to other clients. - Function independently. - Express himself verbally.

Answer = D. RATIONALE: When working with a client who is withdrawn and speaks little, answers briefly, and looks at the floor, the nurse should focus on interacting with the client to decrease withdrawal and establish a nurse-client relationship.

LEGAL A 15-year-old male client on the psychiatric unit shows signs of mild intoxication. When questioned, he states that another client gave him beer, and he refuses to name the client. Which of the following should the nurse do next? - Telephone the client's parents. - Call a community meeting. - Urge the client to tell who gave him the beer. - Call the physician.

RATIONALE: B. In this situation, the nurse should call a community meeting. The community meeting serves as a forum for clients to voice their opinions about the environment, receive feedback from staff and other clients, and discuss community concerns, including exploring the problems of daily living. The community meeting can be used to increase peer support and handle confrontation when necessary. For adolescents, peer pressure is generally more effective in changing behavior than the staff's influence

Psychosocial adaptation; Bipolar After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful? - "I need to restrict eating any foods that contain salt." - "If I forget a dose, I can double the dose the next time I take it." - "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." - "I should increase my fluid intake to five to six 8-ounce glasses of water each day."

RATIONALE: C. A client receiving lithium (Eskalith) is at risk for toxicity, evidenced by diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination, or muscle weakness. Thus, the client's statement about notifying the doctor about possible signs of lithium toxicity reflects accurate knowledge about the drug and successful teaching.

LEGAL HOLDS Which of the following rights does a client lose by being admitted involuntarily to a psychiatric hospital? The right to: - Send and receive mail. - Vote in a national election. - Make a will or legally binding contract. - Sign out of the hospital against medical advice

RATIONALE: D. A person who has been involuntarily committed to a psychiatric hospital loses the right to leave the hospital on his own accord.

PATIENT RIGHTS LEGAL ISSUES The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client, who listens quietly. Which of the following statements made by the nurse would not be accurate about the involuntary admission process - "You're in the hospital because the psychiatrist who saw you earlier thinks that you are unable to care for yourself right now." - "You're free to talk to a lawyer if you'd like to do so." - "You cannot leave the hospital until the physician thinks you can take care of yourself." - "You cannot have any visitors while you're here involuntarily."

RATIONALE: D. Clients have a right to see visitors regardless of admission status.