NCLEX style review

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. HR = 120-140 B. HR = 50-60 C. BP = 100/70 D. BP = 140/80

A

The nurse correctly teaches a client taking the Benzodiazepine Oxazepam (Serax) to avoid excessive intake of: A. cheese B. coffee C. sugar D. shellfish

B

A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. denies confusion by being jovial B. pretends to be someone else C. rationalizes various behaviors D. fills in memory gaps with fantasy

D

Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. carbonated beverages B. aftershave lotion C. toothpaste D. cheese

B

The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to: A. encourage the use of a 12 step program B. help members maintain sobriety C. provide fellowship among members D. teach positive coping mechanisms

B

The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. accept responsibility for own behaviors B. be able to verbalize own needs and assert rights C. set firm and consistent limits with pt D. allow child to establish his own limits and boundaries

A

The nurse understands that electroconvulsive therapy is primarily used in psychiatric care for the treatment of: A. anxiety D/O B. depression C. mania D. schizophrenia

B

Which neurotransmitter has been implicated in the development of Alzheimer's disease? A. acetylcholine B. dopamine C. epinephrine D. serotonin

A

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? A. a rigid posture, restlessness, and glaring B. depression and physical withdrawal C. silence and noncompliance D. hypervigilance and talk of past violent acts

A

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A

The nurse is aware that the following ways in vascular dementia different from Alzheimer's disease is: A. vascular dementia has a more abrupt onset B. the duration of vascular dementia is usually brief C. personality change is common in vascular dementia D. the inability to perform motor activities occurs in vascular dementia

A

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. coronary artery spasm B. bradyarrhythmias C. neurobehavioral deficits D. panic D/O

A

A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful? A. the parents reinforce increased decision making by the pt B. the parents clearly verbalize their expectations for the pt C. the pt verbalizes that family meals are now enjoyable D. the pt tells her parents about feelings of low self esteem

A

For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. they tend to overprotect their children B. usually have a history of substance abuse C. they maintain emotional distance from their children D. they alternate between loving and rejecting their children

A

Group members have worked very hard, and the nurse reminds them that termination is approaching. Termination is considered successful if group members: A. decide to continue B. elevate group process C. focus on positive experience D. stop attending prior to termination

A

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. antisocial personality D/O B. borderline personality D/O C. OCD D. narcissistic personality D/O

A

Mr. Garcia, an attorney who throws books and furniture around the office after losing a case, is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism? A. regression B. projection C. reaction-formation D. intellectualization

A

Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers? A. lack of honesty B. belief in superstition C. show of temper tantrums D. constant need for attention

A

Nurse Daisy is aware that the following pharmacologic agents are sedative-hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is: A. triazolam (halcion) B. paroxetine (paxil) C. fluoxetine (prozac) D. risperidone (risperidal)

A

Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol? A. should report feelings of restlessness or agitation at once B. use sunscreen outdoors on a year-round basis C. be aware you'll feel increased energy taking this drug D. avoid eating sugar-free sweets

A

The nurse collecting family assessment data asks. "Who is in your family and where do they live?" Which of the following is the nurse attempting to identify? A. boundaries B. ethnicity C. relationships D. triangles

A

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for A. mental retardation B. heroin dependence C. addiction in adulthood D. psychological disturbances

B

Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing pt's home environment and relationships outside the hospital B. Exploring nurse's own feelings about suicide C. Discussing the future with the pt D. Referring the pt to a clergyperson to discuss the moral implications of suicide

B

Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? A. reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. readiness to leave the perpetrator and knowledge of resources C. use of drugs or alcohol D. history of previous victimization

B

A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching? A. acetaminophen (tylenol) B. diphenhydramine (benadryl) C. furosemide (lasix) D. isosorbide dinitrate (Isordil)

B

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. psychotherapy B. total abstinence C. AA D. aversion therapy

B

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from: A. acetate accumulation B. thiamine deficiency C. triglyceride buildup D. a below-normal serum potassium level

B

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "why didn't you get someone to drive you" B. "tell me how you feel about the accident" C. "you should know better than to drink and drive" D. "I recommend that you attend an AA meeting"

B

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess? A. restlessness, short attention span, hyperactivity B. physical aggressiveness, low stress tolerance, disregard for the rights of others C. deterioration in social functioning, excessive anxiety, and worry, bizarre behavior D. sadness, poor appetite and sleeplessness, loss of interest in activities

B

Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting: A. splitting B. transference C. countertransferance D. resisitance

B

Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for: A. occasional irritable outbursts B. impaired communication C. lack of spontaneity D. inability to perform self-care activities

B

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. remaining with the pt and staying calm B. Calling a security guard and another staff member for assistance C. Telling pt's husband he must leave at once D. Determining why husband feel so angry

B

Ivy, who is in the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, "I thought the nurse was my mirror. I felt connected only when I saw my nurse." This behavior is known by which of the following terms? A. modeling B. echopraxia C. ego-syntonicity D. ritualism

B

Jennifer, an adolescent who is depressed and reported by her parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect? A. anxiety D/O B. behavioral difficulties C. cognitive impairment D. labile moods

B

Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. student discusses conflicts over drug use B. student accepts a referral to a substance abuse counselor C. student agrees to inform his parents of the problem D. student reports increased comfort with making choices

B

Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. situational B. adventitious C. developmental D. internal

B

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family? A. acknowledge the parent's responsibility B. explain the biological nature of schizophrenia C. refer the family to a support group D. teach the parent's various ways they must change

B

Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in? A. conflict resolution phase B. initiation phase C. working phase D. termination phase

B

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. physical needs B. safety needs C. psychosocial needs D. medical needs

B

A 16-year-old girl has returned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style? A. differentiation B. disengagement C. enmeshment D. scapegoating

C

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. being after 7 days B. not occur at all because the time period for their occurrence has passed C. begin anytime within the next 1-2 days D. being within 2-7 days

C

A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. clozapine (clozaril) B. thiothixene (navane) C. lorazepam (Vatican) D. lithium carbonate (eskalith)

C

A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation of the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe: A. lidocaine (xylocaine) B. procainamide (pronestyl) C. nitroglycerin D. epinephrine

C

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. child cries uncontrollably throughout the examination B. child pulls away from contact with physician C. child doesn't cry when shoulder is examined D. child doesn't make eye contact with nurse

C

After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal? A. 5 g mixed in 250 mL of water B. 15 g mixed in 500 mL of water C. 30 g mixed in 250 mL of water D. 60 g mixed in 500 mL of water

C

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phenylcyclidine (PCP) intoxication B. alochol withdrawal C. opiate withdrawal D. cocaine withdrawal

C

Jun approaches the nurse and tells that he hears a voice telling him that he's evil and deserves to die. Which of the following terms describes the client's perception? A. delusion B. disorganized speech C. hallucination D. idea of reference

C

Kitty, a 9-year-old child has a very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: A. profound B. mild C. moderate D. severe

C

Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first? A. talk about his hallucinations and fears B. refer him for anticholinergic adverse reactions C. assess for possible physical problems such as rash D. call the HCP to get his meds increased to control his psychossis

C

Nurse Fey is aware that the drug of choice for treating Tourette syndrome? A. fluoxetine (prozac) B. fluvoxamine (luvox) C. haloperidol (haldol) D. paroxetine (paxil)

C

Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is: A. obesity B. borderline personality D/O C. major depression D. HTN

C

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. restrict visits with the family until pt begins to eat B. provide privacy during meals C. set up a strict eating plan for the pt D. encourage pt to exercise, which will reduce her anxiety

C

Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when: A. pt verbalizes the reasons for the violent behavior B. pt apologizes and tells nurse that it will never happen again C. no acts of aggression have been observed within 1 hour after the release of 2 of the extremity restraints D. the administered med has taken effect

C

Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should: A. assess skin color and sclera B. assess radial pulse C. take BP D. ask pt to void

C

The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity? A. antacids B. antibiotics C. diuretics D. hypoglycemic agents

C

Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing? A. pt performs ADLs and learns about crafts B. pt is able to prevent aggressive behavior and monitors his use of meds C. pt demonstrates self-reliance and social adaptation D. pt experiences anxiety relief and learns about his symptoms

C

Which factors are the most essential for the nurse to assess when providing crisis intervention for a client? A. pt's communication and coping skills B. pt's anxiety level and ability to express feelings C. pt's perception of the triggering event and availability of situational supports D. pt's use of reality testing and level of depression

C

Which method would a nurse use to determine a client's potential risk for suicide? A. wait for pt to bring up the subject of suicide B. observe pt's behavior for cues of suicide ideation C. question pt directly about suicidal thoughts D. question pt about future plans

C

Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit? A. emphasize the importance of good nutrition to establish normal weight B. ignore the pt's mealtime C. help establish a plan using privileges and restrictions based on compliance with refeeding D. teach pt information about long-term physical consequence of anorexia

C

Which of the following interventions is important for a Cely experiencing a paranoid personality disorder taking olanzapine (Zyprexa)? A. explain effects of serotonin syndrome B. teach pt to watch for extrapyramidal adverse reaction C. explain that the drug is less effective if the pt smokes D. discuss the need to report paradoxical effects such as euphoria

C

A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. avoid discussing pt's perception and feelings B. focus discussions on food and weight C. avoid discussing unrealistic cultural standards regarding weight D. provide objective data and feedback regarding pt's weight and attractiveness

D

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. vomiting, diarrhea, and bradycardia B. dehydration, temp above 101 F, and pruritis C. HTN, diaphoresis, and seizures D. diaphoresis, tremors, and nervousness

D

A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affect." B. "I spend half of my paycheck at the bar" C. "I just drink to relax after work" D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me"

D

Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statements refers to a secondary gain? A. it brings some stability to the family B. it decreases the preoccupation with the physical illness C. it enables the pt to avoid some unpleasant activity D. it promotes emotional support or attention for the pt

D

Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. alcohol withdrawal B. cannabis withdrawal C. cocaine withdrawal D. opioid withdrawal

D

During a conversation with Nurse John with a client, he observes that the client shifts from one topic to the next on a regular basis. Which of the following terms describes this disorder? A. flight of ideas B. concrete thinking C. ideas of reference D. loose association

D

Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that: A. this med may be habit-forming and will be discontinued as soon at the pt feels better B. this med has no serious adverse effects C. the pt should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking this med D. this med may initially cause tiredness, which should become less bothersome over time

D

Mr. Cruz visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Tiffany suspects: A. cyclothimic D/O B. atypical affective D/O C. major depression D, dysthymic D/O

D

Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. characterized by an acute onset and lasts about 1 month B. characterized by a slowly evolving onset and lasts about 1 week C. characterized by a slowly evolving onset and lasts about 1 month D. characterized by an acute onset and lasts hours to a number of days

D

Ricardo, an outpatient in a psychiatric facility is diagnosed with dysthymic disorder. Which of the following statements about dysthymic disorder is true? A. it involves a mood range from moderate depression to hypomania B. it involves a single manic depression C. its a form of depression that occurs in the fall and winter D. its a mood D/O similar to major depression but of a mild to moderate severity

D

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important? A. determine assailant's identity B. preserve pt's privacy C. identify the extent of an injury D. ensure an unbroken chain of evidence

D

The nurse considers a client's response to crisis intervention successful if the client: A. changes coping skills and behavioral patterns B. develops insight into reasons why the crisis occurred C. learns to relate better to others D. returns to his previous level of functioning

D

Tristan is on Lithium and has suffered from diarrhea and vomiting. What should the nurse in-charge do first: A. recognize this as a drug interaction B. give pt Cogentin C. reassure pt that these are common side effects of lithium therapy D. hold the next dose and obtain an order for a stat serum lithium level

D

When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. norepinephrine and lidocaine B. Nifedipine (Procardia) and lidocaine C. nitroglyceride and esmolol D. nifedipine and esmolol

D

Which of the following outcome criteria is appropriate for the client with dementia? A. pt will return to an adequate level of self-functioning B. pt will learn new coping mechanisms to handle anxiety C. pt will seek out resources in the community for support D. pt will follow an establishing schedule for ADLs

D

Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level?

acetylcysteine (mucomyst)

A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal?

chlordiazepoxide (librium)

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority? A. establish adequate daily nutritional intake B. make a contract with nurse that sets target weight C. identify self-perceptions about body size as unrealistic D. verbalize the possible physiological consequences of self-starvation

establish adequate daily nutritional intake

A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority.

remain with pt, reduce external stimuli, encourage low and deep breathing, teach coping measures, encourage physical activity

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect?

seizures