Saunders NCLEX Questions
A client has been admitted to the mental health unit. On admission assessment, the nurse notes that the client was admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client: a. Presents a harm to self b. Requested the admission c. Consented to the admission d. Provided written application to the facility for admission
a. Presents a harm to self Rationale: Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment. Options 2, 3, and 4 describe the process of voluntary admission.
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following? a. "I cannot discuss any client situation with you." b. "If you want to know about Carol, you need to ask her yourself." c. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she's doing great!" d. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"
a. "I cannot discuss any client situation with you." Rationale: A nurse is required to maintain confidentiality regarding the client in the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is option 1. Option 2 is a rather blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options 3 and 4 identify statements that do not maintain client confidentiality. Option 1 is the most direct and correct.
Which statement would indicate the "law and order orientation" found in level 2 of Kohlberg's theory of moral development? a. "If I skip down the hall, will the teacher be mad at me? b. "We will spend time talking about the activities for the week." c. "I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking." d. "If you do all of your class work today without bothering others in the class, you will get an extra 'seed' for your good behavior garden."
a. "If I skip down the hall, will the teacher be mad at me? Rationale: in the law and order orientation of Kohlberg's theory, the child has more concern with society as a whole and emphasis is on obeying laws to maintain social order. The child wants to be considered good by persons whose opinions matter to them. Option 1 is the only option that reflects this criteria. Options 2, 3, and 4 are unrelated to the law and order orientation.
A nursing instructor asked a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is: a. "The child has the ability to think abstractly." b. "The child develops logical thought patterns." c. "The child begins to understand the environment." d. "The child has difficulty separating fantasy from reality."
a. "The child has the ability to think abstractly." Rationale: in the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the concrete operations stage. Option 3 identifies the sensorimotor stage. Option 4 identifies the preoperational stage.
The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. Using Erikson's psychosocial development theory, the appropriate response by the nurse is which of the following? a. "This is a normal behavior at this age." b. "Children usually begin this behavior at age 8 years." c. "This is not normal behavior, and the child should be seen by the physician." d. "The child is very young to begin this behavior and should be brought to the clinic."
a. "This is a normal behavior at this age." Rationale: according to Freud's psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns. Therefore, options 2, 3, and 4 are incorrect.
A maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to: a. Allow the newborn infant to signal a need b. Anticipate all the needs of the newborn infant c. Attend the newborn infant immediately when crying d. Avoid the newborn infant during the first 10 minutes of crying
a. Allow the newborn infant to signal a need Rationale: according to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.
A nurse enters a client's room, and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. Which of the following actions will the nurse take? a. Contact the physician b. Call the client's family c. Persuade the client to stay a few more days d. Tell the client that discharge is not possible at this time
a. Contact the physician Rationale: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parent or guardian. The nurse needs to be familiar with the state in facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws. The best nursing action is to contact the physician.
The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply. a. Restating b. Listening c. Asking the client, "why?" d. Maintaining neutral responses e. Giving advice or approval or disapproval f. Providing acknowledgement and feedback
a. Restating b. Listening d. Maintaining neutral responses f. Providing acknowledgement and feedback Rationale: Some of the therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgement and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing non-verbal encouragement, and summarizing.
A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, the nurse tells the mother to: a. Set limits on the child's behavior b. Ignore the child when this behavior occurs c. Allow the behavior, because this is normal at this age period d. Punish the child every time the child says "no" to change the behavior
a. Set limits on the child's behavior Rationale: According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like no or mine and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements.
A nursing instructor asks a nursing student to present a clinical conference to peers regarding Freud's psychosocial stages of development, specifically the anal stage. The student plans the conference, knowing that which of the following most appropriate relates to this stage of development? a. This stage is associated with toilet training b. This stage is characterized by the gratification of self c. This stage is characterized by a tapering off of conscious biological and sexual urges d. This stages associated with pleasurable and conflicting feelings about the genital organs
a. This stage is associated with toilet training Rationale: generally, toilet training occurs during this period. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage.
A client admitted to the mental health unit is experiencing disturbed thought process and believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? a. Using open-ended questions and silence b. Focusing on self-disclosure regarding food preferences c. Identifying the reasons that the client may not want to eat d. Offering opinions about the necessity of adequate nutrition
a. Using open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.
The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. While conversing with the client, the client says, "I have a secret that I want to tell you. You won't tell anyone else, will you?" The appropriate nursing response is which of the following? a. "No, I won't tell anyone." b. "I cannot promise to keep a secret." c. "If you tell me the secret, I will tell it to your doctor." d. "If you tell me the secret, I will need to document it in your record."
b. "I cannot promise to keep a secret." Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses.
The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? a. Planning short-term goals b. Making appropriate referrals c. Developing realistic solutions d. Identifying expected outcomes
b. Making appropriate referrals Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 3, and 4 identify the tasks of the working phase of the relationship.
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else using Erikson's psychosocial development theory, the appropriate nursing response is which of the following? a. "You need to be concerned." b. "You need to monitor the child's behavior closely." c. "At this age, the child is developing his own personality." d. "You need to provide more praise to the child to stop this behavior."
c. "At this age, the child is developing his own personality." Rationale: according to Erikson, during school-age years (6 to 12 years of age), the child begins to move towards peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The therapeutic response by the nurse is: a. "Have you shared your feelings with your family?" b. "I think we should talk more about your anger with your family." c. "You're feeling angry that your family continues to hope for you to be cured?" d. "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia."
c. "You're feeling angry that your family continues to hope for you to be cured?" Rationale: Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship.
The community health nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication technique for this client? a. "Go on." b. "Sleeping?" c. "You're having difficulty sleeping?" d. "Sometimes, I have trouble sleeping too."
c. "You're having difficulty sleeping?" Rationale: Option 3 uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. Options 1, 2, and 3 are not therapeutic responses.
A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which of the following is the appropriate nursing response? a. "I need to continue with my visits. Your comment reflects lack of knowledge that this disease runs in families." b. "I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever." c. "I agree with you. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husband's use of manipulation." d. "I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions."
d. "I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions." Rationale: Most suicides occur within 3 months after the beginning of improvement, when the client has the energy to carry out the suicidal intentions. Options 1, 2, and 3 are incorrect because they fail to address safety and involve giving false information.
Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The appropriate nursing response is which of the following? a. "What makes you think that I am a vampire?" b. "I'll leave and come back later for your blood." c. "I am not going to hurt you; I am going to help you." d. "It must be frightening to think that others want to hurt you."
d. "It must be frightening to think that others want to hurt you." Rationale: Option 4 helps the client focus on the emotion underlying the delusion but does not argue with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option t3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly.
A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The therapeutic response to the client is: a. "I don't see you as a failure." b. "You have everything to live for." c. "Feeling like this is all part of being ill." d. "You've been feeling like a failure for a while?"
d. "You've been feeling like a failure for a while?" Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings.
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. The appropriate interpretation of the behavior is that the client: a. Needs to be admitted to the hospital b. Needs to be referred to the psychiatrist ASAP c. Requires further treatment and is not ready to be discharged d. Is displaying typical behaviors that can occur during termination
d. Is displaying typical behaviors that can occur during termination Rationale: In the termination phase of a relationship, it is normal for the client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.
The client was admitted involuntarily to the mental health unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital and the nurse does not allow the client to leave. Which of the following represents the legal ramifications associated with the nurse's behavior? a. The nurse will be charged with assault b. The nurse will be charged with slander c. The nurse will be charged with imprisonment d. No charge will be made against the nurse because the nurse's actions are reasonable
d. No charge will be made against the nurse because the nurse's actions are reasonable Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse's actions are reasonable.
A clinic nurse is preparing to discuss the concepts of moral development with a mother. The nurse understands that according to Kohlberg's theory of moral development, in the preconventional level, moral development is thought to be motivated by which of the following? a. Peer pressure b. Social pressure c. Parents' behavior d. Punishment and reward
d. Punishment and reward Rationale: in the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are incorrect.
Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? a. Working b. Trusting c. Orientation d. Termination
d. Termination Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any resolved feelings related to loss may resurface during this phase. Options 1, 2, and 3 are incorrect.
The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines: a. That the physician will provide the informed consent b. That an informed consent does not need to be obtained c. That an informed consent should be obtained from the family d. That an informed consent needs to be obtained from the client
d. That an informed consent needs to be obtained from the client Rationale: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client.
The nurse employed in a mental heath unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following? a. The client will resist treatment measures b. The client will be angry and will refuse care c. The client's family will resist treatment measures d. The client will participate in the planning of the care and treatment plan
d. The client will participate in the planning of the care and treatment plan Rationale: Generally, the client seeks voluntary admission. A voluntary admission permits the client to make a written application for admission. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1, 2, and 3 are not characteristics of this type of admission.