NCLEX practice Exam 2

Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. 1. Electrolyte levels 2. Exercise patterns 3. Intake and output 4. Pupillary response 5. Elimination patterns 6. Deep tendon reflexes

1. Electrolyte levels 3. Intake and output 5. Elimination patterns

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. 1. The client will keep scheduled appointments. 2. The client's physical wounds will begin to heal properly. 3. The client will verbalize feelings about the abusive event. 4. The client will resolve feelings of anxiety related to the event. 5. The client will participate in the various aspects of the treatment plan.

1. The client will keep scheduled appointments. 2. The client's physical wounds will begin to heal properly. 3. The client will verbalize feelings about the abusive event. 5. The client will participate in the various aspects of the treatment plan.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

2. Rapid heartbeat or anxiety

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright

2. Seizure activity

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

2.Evidence of the client's disturbed body image

The nurse is caring for a client who has been prescribed disulfiram. Which statement by the client indicates to the nurse the need for further teaching about this medication? 1. "I'll have to check my aftershave lotion." 2. "I must be careful taking cold medicines." 3. "As long as I don't drink alcohol, I'll be fine." 4. "I'll have to be careful with the ingredients I use for cooking."

3. "As long as I don't drink alcohol, I'll be fine."

A client is prescribed a monoamine oxidase inhibitor. What is the primary reason the nurse needs to assess this client closely? 1.Risk of liver damage may be increased. 2.Bradycardia and hypotension may indicate toxicity. 3.Headache, hypertension, and nausea and vomiting may indicate toxicity. 4.Hypotensive crisis may be precipitated by foods rich in tyramine and tryptophan.

3. Headache, hypertension, and nausea and vomiting may indicate toxicity.

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? 1. Delay such planning until the client asks to participate in milieu. 2. Encourage the client to play solitaire while providing a deck of cards. 3. Provide a structured daily program of activities, and encourage the client to participate. 4. Offer the client a menu of daily activities and insist that the client participate in all of them.

3. Provide a structured daily program of activities, and encourage the client to participate.

A monoamine oxidase inhibitor is prescribed for a client. Which sign or symptom is indicative of toxicity? 1.Lethargy 2.Depression 3.Restlessness 4.Constipation

3. Restlessness

Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1. Frequently expresses suicidal ideations 2. Leaves the dayroom when anyone else enters 3. Will take personal items from other clients' rooms 4. Requires constant reassurance whenever required to make a decision

3. Will take personal items from other clients' rooms

At what time of day does the nurse recommend that a child prescribed methylphenidate be given the last dose of the day of the medication? 1.At bedtime 2.With a bedtime snack 3.Just before the noontime meal 4.In the morning, 2 hours before breakfast

3.Just before the noontime meal

A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result should the nurse review before administering the first dose of this medication? 1.Platelet count 2.Blood clotting tests 3.Liver function studies 4.Complete blood count

3.Liver function studies

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the health care provider before administering the medication? 1.Hypothyroidism 2.Diabetes mellitus 3.Narrow-angle glaucoma 4.Coronary artery disease

3.Narrow-angle glaucoma

A client diagnosed with depression has a prescription for sertraline. The nurse should withhold the medication and question the prescription if the client has a history of which disorder? 1.Diabetes mellitus 2.Myocardial infarction 3.Phenelzine sulfate use 4.Irritable bowel syndrome

3.Phenelzine sulfate use

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 1. "I need you to sign a form before leaving." 2. "You will get sick if you go out in the rain." 3. "How old are you? Your father must no longer be living." 4. "Let's have a cup of coffee, and you can tell me about your father."

4. "Let's have a cup of coffee, and you can tell me about your father."

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? 1. Coarse hand tremor, agitation, hallucinations, and hypotension 2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3. Hypotension, stupor, agitation, headache, and auditory hallucinations 4. Fever, hypertension, changes in level of consciousness, and hallucinations

4. Fever, hypertension, changes in level of consciousness, and hallucinations

The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.

4. Get up slowly when changing positions.

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? 1.Isolating self 2.Inability to cope 3.Low self-esteem 4.Risk for self-harm

4.Risk for self-harm