NCLEX 1 Pretest Mistakes Saunders

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?" Rationale: Explanations would begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications

The nurse creating a plan of care for the client demonstrating paranoia would include which interventions in the plan of care? Select all that apply. 1 Ask permission before touching the client. 2Provide a warm, social approach to the client. 3Eliminate all unnecessary physical contact with the client. 4Defuse any anger or verbal attacks with a nondefensive stance. 5Use simple and clear language when communicating with the client.

1 Ask permission before touching the client. 3Eliminate all unnecessary physical contact with the client. 4Defuse any anger or verbal attacks with a nondefensive stance. 5Use simple and clear language when communicating with the client. Rationale: When caring for a client with paranoia, the nurse would ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language would be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse would avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

A client is being seen at the primary health care provider (PHCP) office. The client has a history of schizophrenia and has been taking a new psychotropic medication for 3 weeks. Which finding(s) indicate a need for follow-up? Select all that apply. 1The client has reported sleeping less. 2The client's cholesterol level is elevated. 3The client reports a decrease in appetite. 4The client gained 8 pounds since the last visit. 5The client's blood pressure is increased from baseline.

2The client's cholesterol level is elevated. 4The client gained 8 pounds since the last visit. 5The client's blood pressure is increased from baseline. Clients with schizoaffective disorders are at higher incidence for metabolic syndrome and diabetes mellitus due to the side effects experienced while taking psychotropic medications, such as increase in appetite, weight gain, increased cholesterol levels, and increased blood pressure. Psychotropic medications cause sedation; therefore option 1 is incorrect.

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. 1A birthday of March 30 2A loss of interest in hobbies 3A suicide attempt 6 months ago 4Adopted by family at age 14 months 5Brain scan shows increased blood flow to the frontal lobes 6Magnetic resonance imaging shows temporal lobe atrophy

A birthday of March 30 A loss of interest in hobbies A suicide attempt 6 months ago Magnetic resonance imaging shows temporal lobe atrophy A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased; no data support that adoption itself increases the risk for schizophrenia.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain Imaging studies of the brains of individuals with confirmed diagnoses of schizophrenia have shown the consistent atrophy of the lateral and/or third ventricles.

A client diagnosed with schizophrenia is taking haloperidol. The nurse understands that this medication will exert its therapeutic effect through which mechanism? 1Blocking serotonin reuptake 2Inhibiting the breakdown of released acetylcholine 3Blocking the uptake of norepinephrine and serotonin 4Blocking dopamine from binding to postsynaptic receptors in the brain

Blocking dopamine from binding to postsynaptic receptors in the brain Haloperidol is an antipsychotic. Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Fluoxetine hydrochloride is a potent serotonin reuptake blocker. Donepezil hydrochloride inhibits the breakdown of released acetylcholine. Imipramine hydrochloride blocks the uptake of norepinephrine and serotonin.

How can the nurse determine whether cardiopulmonary resuscitation (CPR) is needed for a client with a shockable rhythm?

CPR is a part of the management for both shockable and nonshockable rhythms. CPR would be initiated for any pulseless or bradycardic rhythm, such as ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and asystole. Just because a rhythm is shockable does not mean that there is a pulse. CPR is performed between defibrillations to help tissue and organ perfusion until return of spontaneous circulation is achieved or CPR efforts are ceased.

The nurse would monitor the client prescribed thioridazine hydrochloride carefully for which adverse effect?

Cardiac dysrhythmias Thioridazine hydrochloride is an antipsychotic medication that may be prescribed for the schizophrenic client when other medications have failed to manage the symptoms. Cardiac dysrhythmias are an adverse effect of thioridazine.

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1During the entire family visit, the client presented with an expressionless, blank look. 2The client demonstrated minimal response to the news that his discharge had been postponed. 3The client grimaced during the entire therapy session that focused on finding one's personal joy. 4During grief therapy, the client was observed laughing while another client described the death of a parent.

During the entire family visit, the client presented with an expressionless, blank look. Rationale: A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.

Which goal addresses the therapeutic management needs of a client with schizophrenia who is experiencing hallucinations?

Facilitate the client's awareness that the hallucination is not the reality of the world. The goal of nursing interventions for the therapeutic management of hallucinations is to first help the client increase awareness so that they can distinguish between the misperception and reality. Having insight into why the hallucinations occur and possessing strategies to manage them effectively are skills needed to attain the stated goal of awareness of reality. Ignoring a hallucination is inappropriate and can be harmful. All nursing interventions would be provided with care and in a therapeutic manner; this is not a client-oriented goal but a nursing responsibility.

The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.

I need to decrease my oral fluids when I start this medication. I need to report headache and drowsiness to my primary health care provider since these symptoms could be related to my desmopressin. In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an analog of ADH. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin is started, oral fluids would be decreased to prevent water intoxication. Therefore, clients with diabetes insipidus would decrease their oral fluid intake when they start desmopressin. Headache and drowsiness are signs of water intoxication in the client taking desmopressin and need to be reported to the primary health care provider. Desmopressin does not turn urine orange. The amount of urine would decrease, not increase, when desmopressin is started. Desmopressin does not cause pancreatitis.

The ambulatory care nurse is providing instructions to a client after a cystoscopy. Which statement by the client indicates a need for further teaching?

If I notice any pink-tinged urine, I would contact my doctor. The client is instructed that pink-tinged urine and burning on urination are expected for 1 to 2 days after the procedure. Increased fluid intake is encouraged. Application of heat to the lower abdomen, administration of mild analgesics, and the use of sitz baths may relieve discomfort. The client also is advised to avoid alcoholic beverages for 2 days after the test.

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?

Impaired pain perception Rationale: Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia.

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1Including the client's support system in the teaching 2Facilitating weekly maintenance therapy for the client 3Having the client restate discharge goals and strategies 4Stressing the importance of client compliance with the medication plan

Including the client's support system in the teaching Rationale: Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective.

The nurse caring for a client with a diagnosis of acute schizophrenia would use which approach when planning care?

Let the client act out initially, and use the quiet room and restraints as needed. In the acute phase, the nurse must assume responsibility for planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Including the client in decision making at this point is incorrect because these actions do not provide a structured routine.

A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result would the nurse review before administering the first dose of this medication?

Liver function studies Risperidone is an atypical antipsychotic. A baseline assessment of renal and liver function needs to be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level.

A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse would obtain which medication from the emergency drawer of the medication cart?

Phentolamine Rationale: The antidote for hypertensive crisis is phentolamine. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present.

The health care team is performing high-quality cardiopulmonary resuscitation (CPR) on a client in cardiac arrest. Once the client is attached to a monitor, it is determined that a shock is not advised. CPR is continued, and the nurse determines that which additional action would be taken next by the health care team?

Prepare to administer epinephrine For nonshockable rhythms there are algorithms that are followed to get a pulse and rhythm back. Continuing CPR is a priority, followed by administering epinephrine every 3 to 5 minutes. An airway needs to be established, and potential reversible causes need to be investigated. If a rhythm and pulse come back, the monitor will continue to identify whether it is shockable.

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply.

Transfusions Splenectomy Corticosteroid medication Immunosuppressive agents Idiopathic autoimmune hemolytic anemia is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

The nurse is preparing to administer filgrastim to the client. Which route of administration would the nurse determine is the most appropriate for this medication?

Subcutaneous Filgrastim is a granulocyte colony-stimulating factor produced by human recombinant DNA technology. It is given by subcutaneous injection or continuous intravenous infusion. Filgrastim is a medication that supports the body in making more white blood cells to help fight infections. It is typically administered by health practitioners via subcutaneous (SQ) injection. Subcutaneous injections direct the medicine into the layer of tissue or fat under the skin. This allows the medicine to be absorbed slowly and thoroughly into the bloodstream across the day.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1When told that a beloved pet has died, the client responds, "OK." 2The client giggled while describing being physically abused as a child. 3The client's facial expressions are unchanged during the entire admission process. 4When staff members attempt to engage the client in conversation, the client only mumbles.

The client giggled while describing being physically abused as a child. Rationale:An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? 1The client remains in the same physical position for hours. 2The client is convinced that the curtains are actually ghosts. 3The client looks for a cat when someone says, "It's raining cats and dogs." 4The client repeatedly asks, "Can you see my dead sibling over by the door?"

The client is convinced that the curtains are actually ghosts. A delusion is a personal belief that is the product of dysfunctional processing of information derived from external reality. This cognitive processing dysfunction is the basis of schizophrenia. Catatonia is a stuporous state that renders the client incapable of physical movement. Magical thinking is a result of concrete thinking that causes the client to interpret a statement literally. Hallucinations are the result of distortions in perceptions of the senses, but they are not reliant on internal or external stimuli.

Coal tar has been prescribed for the client with psoriasis, and the nurse provides instructions to the client regarding this treatment. Which statement by the client indicates a need for further instruction?

The medication can cause diarrhea. Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, frequently can stain the skin and hair, and can cause phototoxicity. It does not cause diarrhea.

The nurse assigned to care for a client diagnosed with acute depression would be appropriate in making which statement to the client? 1"You look lovely today." 2"You're wearing a new blouse." 3"Don't worry; everyone gets depressed once in a while." 4"You will feel better when your medication starts to work."

You're wearing a new blouse. Rationale: A client who is depressed sees the negative side of everything. Telling the client that they look lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client would not be told not to worry, that everyone gets depressed once in a while, or that they will feel better because such statements are inappropriate and minimize the client's feelings.

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1"Why do you believe your roommate would steal from you?" 2"I'll see if I can arrange for you to move in with a different roommate." 3"Tell me more about your belief that your roommate would steal from you." 4"I hear what you are saying, but I have no reason to believe your roommate steals."

I hear what you are saying, but I have no reason to believe your roommate steals. Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1ncessant talking and sexual innuendos 2Grandiose delusions and poor concentration 3Outlandish behaviors and inappropriate dress 4Nonstop physical activity and poor nutritional intake

Nonstop physical activity and poor nutritional intake Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.