Click here to view the questions.

1. D. The goal is to implement suicide precautions because the danger of suicide is when the depression lifts and the client has the energy to formulate a plan. The nurse would not encourage her to go home (1) where she could not be observed constantly. She could be moved into a room with other clients (2), but this is not the priority concern.

2. C. Mazuka is a made-up word or neologism. This characteristic is frequently present with the disorder and is a part of associative looseness. Answer (1) is not incorrect, but answer (3) is more specific. Flight of ideas is observed with a manic episode.

3. B. Because a person with this disorder tends to manage his or her life through manipulation of others, when it doesn’t work, the anxiety level goes up. The nurse should never allow the client to manipulate. Answers (2) and (4) are not true.

4. A. Depersonalization is the feeling or subjective experience of separating oneself or alienation; it is also the state in which the client cannot distinguish the self from others and involves disintegration of the ego-often observed in schizophrenics as a flight from reality.

5. D. Assuming responsibility for one’s behavior includes acknowledging the behavior and may include a statement of one’s current status. It does not include making excuses, focusing outside of oneself, or blaming another.

6. C. When clients make up stories or lies, it is called confabulation. This is an attempt to fill in memory gaps caused by the destruction of the neurons. This process protects their self-esteem and should not be discouraged or confronted.

7. C. While a good nursing care plan is important, the priority would be to get the client mobilized. Even without a specific diagnosis, the nurse will realize that part of what is happening with the client is a depressed mood. Providing a structured plan of activities for the client to follow will help his mood to lift and provide a focus so that he will not be centered on internal suffering.

8. B. The major goal in crisis treatment centers is to have the client return to a prior level of functioning. At this time in a crisis, it is not therapeutic to work on the dynamics underlying the symptom (2) or make long-range plans (3). Accepting their illness (4) may be a part of returning to a prior level of functioning.

9. B. Anticipating demands (rather than ignoring them) from a hypochondriacal client will break the pattern of demanding behavior. These clients are usually fearful and anxious. Spending time with the client will be reassuring and therapeutic. Assigning various staff members (2) may be useful so no one will become overwhelmed, but it is not the primary approach.

10. C. Simply offering comfort by staying with the client and being open for communication is the most therapeutic. The other responses place an additional burden on the client if she does not wish to talk.

11. B. The best response when a client has the diagnosis of schizophrenia is to validate reality by saying the nurse doesn’t hear anything and then to explore real feelings, like fear. Answer (1) is not enough to be therapeutic; answers (2) and (4) give validity to the voices if, in fact, the client is hallucinating.

12. D. Most suggestible of suicide is the sudden sense of satisfaction or relief (perhaps from finally making the decision to commit suicide) and detachment. Hostility (1), identifying with others (2), or thinking of the future (4) do not as clearly suggest suicidal thinking.

13. D. Be positive, definite, and specific about expectations. Do not give depressed clients a choice or try to convince them to get out of bed. Physically assist the client to get up and dressed to mobilize her. Do not allow her to remain in bed (4) or try to convince her by quoting the rules of the unit (1).

14. A. A goal for this disorder should be broad-based and general, like establishing a safe, supportive environment. Other answers would more directly refer to implementation of the goal strategies.

15. A. Setting limits is important to avoid rejection of the other clients with subsequent lowering of self-esteem. Confronting the client (1) will not be productive and may just increase the annoying activity. Ignoring the behavior (2) will also be nontherapeutic, and the other clients on the unit will become even more hostile. This client will not be able to follow a rigid plan.

1. When a depressed client becomes more active and there is evidence that her mood has lifted, an appropriate goal to add to the nursing care plan is to

a. Encourage her to go home for the weekend.
b. Move her to a room with three other clients.
c. Begin to explore the reasons she became depressed.
d. Monitor her whereabouts at all times.

2. One day the nurse overhears a client with the diagnosis of schizophrenia talking to herself. She is saying, “The mazukas are coming. The mazukas are coming.” Her use of the word mazuka is most likely

a. An example of associative looseness.
b. A manifestation of dyslexia.
c. A neologism.
d. Flight of ideas.

3. Persons with personality disorders tend to be manip ulators. Which principle is it important for the nurse to know in planning the care of a person with this diagnosis?

a. The nurse should appeal to the client’s sense of loyalty in adhering to the rules of the community.
b. When the client’s manipulations are not successful, anxiety will increase.
c. The establishment of a nurse-client relationship will decrease the client’s manipulations.
d. The nurse should allow manipulation so as to not raise the client’s anxiety.

4. The best explanation for the term depersonalization, as seen in schizophrenics, is

a. A flight from reality related to oneself or the environment.
b. A mechanism seen in chronic schizophrenia.
c. The client cannot tolerate personal relationships.
d. The client personalizes all threats and uses projection.

5. A 16 year old is hospitalized for adolescent adjustment problems. After assessing her, the nurse’s first objective is to establish a nurse-client relationship. The next day, the nurse is late for the appointment. Knowing that the client has difficulty assuming responsibility for her own behavior, the nurse would like to use this situation as an opportunity for role modeling. The most appropriate statement the nurse could make is

a. “Oh, you are here. I thought we’d be arriving at the same time.”
b. “What do you mean you are angry with me? I bet you keep people waiting.”
c. “Thank goodness you are still here; I just had a flat tire.”
d. “I’m late. I apologize.”

6. A client has the diagnosis of cognitive disorder-Alzheimer’s disease. The client is constantly making up stories that are untrue. This characteristic of the disease is called

a. Lability.
b. Memory loss.
c. Confabulation.
d. Senility.

7. A 60-year-old male client has been admitted to the psychiatric unit, with symptoms ranging from fatigue, an inability to concentrate, an inability to complete everyday tasks, to refusal to care for himself and preferring to sleep all day. One of the first interventions should be aimed at

a. Talking to his wife for cues to help him.
b. Encouraging him to join activities on the unit.
c. Developing a structured routine for him to follow.
d. Developing a good nursing care plan.

8. The treatment in crisis intervention centers is specifically intended to help clients

a. Make long-range plans for the future.
b. Return to prior levels of functioning.
c. Accept their illness.
d. Understand the dynamics underlying symptoms.

9. A female client has just received the diagnosis of hypochondriasis. This client continually focuses on gastrointestinal problems and constantly rings for a nurse to meet her every demand. The best nursing approach is to

a. Assign various staff members to work with the client so no staff member will become negative.
b. Anticipate the client’s demands and spend time with her even though she does not demand it.
c. Ignore the demands because the nurse knows it is not necessary to respond.
d. Provide for the client’s basic needs, but do not respond to her every demand, which reinforces secondary gains.

10. A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, “I’m feeling sad. I don’t want to talk now.” The nurse’s best response would be

a. “It will help you feel better if you talk about it.”
b. “Sometimes it helps to talk.”
c. “I’ll stay with you a few minutes.”
d. “I’ll come back when you feel like talking.”

11. When the nurse is talking with a schizophrenic client, she suddenly says, “I’m frightened, do you hear that? Terrible things.” Which initial response by the nurse would be most appropriate?

a. “Who is saying terrible things to you.”
b. “I don’t hear anything, but you do seem frightened.”
c. “I don’t hear anything.”
d. “What is someone saying to you?”

12. When assessing a client for possible suicide, an important clue would be if the client

a. Is hostile and sarcastic to the staff.
b. Begins to talk about leaving the hospital.
c. Identifies with problems expressed by other clients.
d. Seems satisfied and detached.

13. A depressed client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. The most appropriate nursing action is to

a. Tell her the rules of the unit are that no client can remain in bed.
b. Suggest she better get out of bed or she will go hungry later.
c. Allow her to remain in bed until she feels ready to join the other clients.
d. Tell her that the nurse will assist her out of bed and help her to dress.

14. A client is suffering from post-traumatic stress disorder following a rape by an unknown assailant. One of the primary goals of nursing care for this client would be to

a. Establish a safe, supportive environment.
b. Discuss the client’s nightmares and reactions.
c. Control aggressive behavior.
d. Deal with the client’s anxiety.

15. A client has the diagnosis of manic episode. Her disruptive behavior on the unit has been increasingly annoying to the other clients. One intervention by the nurse might be to

a. Set limits on the client’s behavior and be consistent in approach.
b. Ignore the client’s behavior, realizing it is consistent with her illness.
c. Tell the client she is annoying others and confine her to her room.
d. Make a rigid, structured plan that the client will have to follow.

[ANSWERS & RATIONALE] NCLEX Questions for Psychosocial Integrity

Click here to view the Physiological Adaptation NCLEX questions.

1. A. The parathyroid glands regulate calcium in the body. Excessive activity results in calcium leaving the bones and teeth to enter the bloodstream. This makes the bones more brittle and susceptible to fracture.

2. C. Peritonitis is a grave complication with peritoneal dialysis. Hemodialysis may be necessary until infection clears. Excess fluid and protein effluent into the peritoneum also complicate care. Use of aseptic technique is essential.

3. B. Carbon dioxide is insufflated into the abdomen during a laparoscopic cholecystectomy. It may irritate the diaphragm and cause referred shoulder pain. This client’s complaint is a common response to this operation, so telling the client will be reassuring.

4. C. Moon face, thin extremities, and buffalo hump are characteristics of Cushing’s syndrome (adrenocortical hyperfunction). A positive Chvostek’s sign (3) is seen with primary aldosteronism; butterfly rash (1) is seen with lupus.

5. B. On dorsiflexion of the foot, the client will experience upper posterior pain in the calf if a clot is present. This is termed Homan’s sign. Kernig’s sign (1) indicates presence of meningeal irritation; Hegar’s sign (2) is softening of the uterus; Brudzinski’s sign (4), in which flexion of the head causes flexion of the knees and thighs, is also a sign of meningeal irritation.

6. D. The client’s complaints are consistent with meningeal irritation from bleeding into the subarachnoid space; therefore, she needs immediate transfer to an acute care setting.

7. C. Adult respiratory distress syndrome is a grave complication of pancreatitis. Pulmonary edema due to administration of large volumes of IV fluids and direct extension of inflammation resulting in pleural effusion are also seen. Pulmonary complications are associated with a poor prognosis. The other distractors are the more common presenting symptoms of pancreatitis.

8. C. The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle.

9. A. Obesity causes a reduced insulin binding at receptor sites and this leads to pancreatic hypersecretion of insulin and eventual pancreatic cell exhaustion.

10. C. When spinal fluid is lost through a leak or the client is dehydrated, a severe headache can occur, which may last several days. Numbness (2) and no urge to void (4) would be expected with spinal anesthesia unless it continues for several hours postop. The complication of hiccoughs (1) can be associated with abdominal surgery, but is not attributable to spinal anesthesia.

11. D. Clinical manifestations of Cushing’s syndrome include water retention, moon face, hirsutism, and purple striae.

12. B. Lethargy may indicate impending encephalopathy and dictate the need for client safety measures. Fatigue is expected due to anemia, shortness of breath due to ascites, and nausea due to GI vascular congestion, but these are not as grave as lethargy.

13. B. Urinary stasis, renal infection, and dehydration predispose the client to the formation of renal calculi, which may or may not require surgery.

14. B. Peptic ulcer disease is characteristically gnawing epigastric pain that may radiate to the back. Vomiting usually reflects pyloric spasm from muscular spasm or obstruction. Cancer (1) would not evidence pain or vomiting unless the pylorus was obstructed.

15. D. The LVN must be sure that the physician has written orders. Stripping and milking chest tubes (1) is allowed only with a physician’s order because it can cause excessive negative pressure, which could damage the lung tissue. Chest tubes are milked away from the client toward the drainage receptacle. LVNs are legally allowed to do this intervention.

1. The client with hyperparathyroidism should have extremities handled gently because

a. Decreased calcium bone deposits can lead to pathologic fractures.
b. Edema causes stretched tissue to tear easily.
c. Polyuria leads to dry skin and mucous membranes that can break down.
d. Hypertension can lead to a stroke with residual paralysis.

2. The nurse will evaluate for the most significant complication in clients undergoing chronic peritoneal dialysis, which is

a. Dyspnea.
b. Hypotension.
c. Peritonitis.
d. Pulmonary embolism.

3. A female client had a laparoscopic cholecystectomy this morning. She is now complaining of right shoulder pain. The nurse would explain to the client this symptom is

a. Expected after general anesthesia.
b. Common following this operation.
c. Indicative of a need to use the incentive spirometer.
d. Unusual and will be reported to the surgeon.

4. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical hyperfunction. In assessing the client, an observable sign the nurse would chart is

a. Butterfly rash on the face.
b. Positive Chvostek’s sign.
c. Moon face.
d. Bloated extremities.

5. Thrombophlebitis is a common complication following vascular surgery. Which of the following signs indicates that a possible thrombus has occurred?

a. Kernig’s sign.
b. Homan’s sign.
c. Brudzinski’s sign.
d. Hegar’s sign.

6. A 16-year-old girl has a known arteriovenous malformation of the middle cerebral artery. In talking to the school nurse, she complains of a headache and stiff neck. The nurse would take which of the following actions?

a. Have the client rest for 2 hours, then reevaluate the situation.
b. Send her home right away to rest.
c. Call her mother and have her picked up from school to see the physician.
d. Make preparations for emergency transfer to an acute care setting.

7. The assessment finding that should be reported immediately should it develop in the client with acute pancreatitis is

a. Decreased bowel sounds.
b. Nausea and vomiting.
c. Shortness of breath.
d. Abdominal pain.

8. When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the

a. Impulse to begin atrial contraction.
b. Impulse to traverse the atria to the AV node.
c. Impulse to travel to the ventricles.
d. SA node to discharge the impulse to begin atrial depolarization.

9. The non-insulin-dependent diabetic who is obese is best controlled by weight loss because obesity

a. Reduces insulin binding at receptor sites.
b. Reduces pancreatic insulin production.
c. Reduces the number of insulin receptors.
d. Causes pancreatic islet cell exhaustion.

10. Following spinal anesthesia, a client is brought into the recovery room. The assessment data that indicates a complication of anesthesia has developed is

a. Hiccoughs.
b. No urge to void.
c. Headache.
d. Numbness in legs.

11. The RN should assess for which of the following clinical manifestations in the client with Cushing’s syndrome?

a. Unexplained weight gain, energy loss, and cold intolerance.
b. Hypertension, diaphoresis, nausea, and vomiting.
c. Tetany, irritability, dry skin, and seizures.
d. Water retention, moon face, hirsutism, and purple striae.

12. When a client is in liver failure, which of the following behavioral changes is the most important assessment to report?

a. Nausea.
b. Lethargy.
c. Shortness of breath.
d. Fatigue.

13. Conditions known to predispose to renal calculi formation include

a. Polyuria.
b. Dehydration, immobility.
c. Presence of an indwelling Foley catheter.
d. Glycosuria.

14. A female client complains of gnawing midepigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out

a. Chronic gastritis.
b. Peptic ulcer disease.
c. Cancer of the stomach.
d. Pylorospasm

15. A client is on a disposal water-seal system with chest tubes in place. The charge nurse assigns the LVN to milk the chest tubes to maintain patency. The RN understands that the correct LVN action is to

a. Milk the tubes toward the client.
b. Tell the charge nurse that this assignment is not appropriate for LVNs.
c. Complete the assignment and chart the intervention in the client’s record.
d. Check that the physician has written orders to milk the chest tubes.

Physiological Adaptation NCLEX Questions [ANSWERS & RATIONALE]

Below is the NCLEX RN and NCLEX PN Examination passing rates for the year 2011 released by National Council of State Boards of Nursing.

A chart that shows quarterly and yearly volume and pass rate data for the NCLEX-RN and NCLEX-PN examinations.

The data includes the number of candidates taking the NCLEX Examination and the percentage of passing, by type of candidate.

Table of Pass Rates 2011 4q

Nclex Stats 2011 4q

Below is the NCLEX RN and NCLEX PN Examination passing rates for the 4th quarter of 2011 released by National Council of State Boards of Nursing.

The data includes the number of candidates taking the NCLEX Examination and the percentage of passing, by type of candidate.

Table of Pass Rates 2011 4q

Nclex Stats 2011 4q

Click here to view the Pharmacological and Parenteral Therapies questions.

1. A. Furadantin antimicrobial activity is more potent in an acid urine. Ascorbic acid or vitamin C tablets acidify the urine.

2. A. These signs, in addition to laryngeal edema, are characteristic of an allergic reaction that is, less spe- cifically, a transfusion reaction. Chills, increased temp- erature, and pain in the kidney region are indications of a hemolytic reaction.

3. B. Coumadin therapy is contraindicated in the pregnant woman because it crosses the placenta. The pregnant client should be taught heparin administration with a heparin lock if anticoagulation therapy must be continued. The arthritic client (2) may take aspirin or NSAIDs, which potentiate the effects of Coumadin, and should be watched for gastrointestinal bleed, as should the client with ulcer disease (4).

4. D. Alterations in vital signs could be an indication of side effects of nebulizer medication. The client should be in sitting position, either in the bed or in a chair. Postural drainage would not be done before IPPB therapy. The nurse would not leave the client during this treatment.

5. B. Maintaining neutropenic precautions is the most important implementation for this client. The client is at risk for infection. Low neutrophil and white blood cell counts are often found in clients with aplastic anemia or malignancies or in clients who have received cytotoxic therapy. These low blood counts are most likely due to the Prevacid, trazadone, and Zoloft. Administration of blood (1) is not indicated; frequent vital signs (2) is important, but not the highest priority; continuing the medications that are the most likely cause of the low blood count (4) will only make the situation worse.

6. A. These side effects may be present with this medication, but may be alleviated by taking the drug in the evening. Often, taking one dose in the evening will minimize the sedation. The nurse needs to follow up with this client and report to the physician.

7. B. Short-acting insulin is withdrawn first in order to prevent possible contamination of the short-_acting insulin bottle by the longer-acting insulin.

8. A. A blood transfusion should be started slowly (from 25 to 50 drops per minute) for the first 15 minutes because slow administration allows time to observe for an adverse reaction. Most reactions occur in the first 15 minutes. Continuing rate is 100 mL/hr.

9. B. Aspirin impedes clotting by blocking prosta-glandin synthesis, which can lead to bleeding. A side effect of prednisone is gastric irritation, also leading to bleeding. Tarry stools indicate bleeding in the upper GI system.

10. D. Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals (1). Due to danger of bleeding, missed doses (3) should not be made up.

11. B. If dopamine has a positive effect, it will cause vasoconstriction peripherally, but increase renal perfusion and the blood pressure will rise. The cardiac index will also rise and the PCWP should decrease.

12. C. Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KCl is also added to the infusion.

13. B. Foods high in oxalate include spinach, green and wax beans, beets, and chocolate.

14. B. Mydriatic drugs are used preoperatively so that the pupil is widely dilated. Either atropine sulfate or epinephrine HCl is commonly used. Pilocarpine (3) and carbamylcholine (2) are miotics used for glaucoma and certain types of lens implants. Timolol maleate (4) is a beta blocker used for glaucoma.

15. D. Beta blockers act to decrease heart rate and force of contraction and reduce vasoconstriction by antagonizing Beta receptors in the myocardium and vasculature. Choices (1) and (2) refer to the action of nitrates as well as Calcium Channel Blockers such as Diltiazem. Choice (3) is not applicable.

1. The client who is receiving Furadantin for a urinary tract infection may also receive ascorbic acid. The rationale for this additional agent is to

a. Acidify the urine.
b. Alkalinize the urine.
c. Fortify mucosal resistance.
d. Promote tissue repair.

2. A client receiving a blood transfusion begins to wheeze and her skin becomes flushed with hives. The nurse knows that these symptoms are characteristic of a (n)

a. Allergic reaction.
b. Thrombic crisis.
c. Hemolytic reaction.
d. Transfusion reaction.

3. When assessing a client for Coumadin therapy, the condition that will exclude this client from Coumadin therapy is

a. Diabetes.
b. Pregnancy.
c. Peptic ulcer disease.
d. Arthritis.

4. The most important nursing action for clients on IPPB therapy with a nebulizer is to

a. Start the IPPB treatment and leave the client to complete it.
b. Make the client comfortable in a supine position during the treatment.
c. Complete postural drainage before IPPB therapy.
d. Monitor blood pressure, pulse, and respirations.

5. You are caring for a client who has been on Prev-acid, trazadone, and Zoloft for the past 8 weeks. This client has an absolute neutrophil count of 300/mm3 and a white blood cell count of 1500/mm3. The nurse should consider which of the following implementations as the priority?

a. Frequent vital signs.
b. Maintaining neutropenic precautions.
c. Regularly scheduled administration of Prevacid, trazadone, and Zoloft to maintain blood levels.
d. Rapid administration of packed cells to raise blood count.

6. A client who recently started taking a daily dose of the drug methyldopa (Aldomet) for hypertension complains of drowsiness and lethargy when the nurse makes a home visit. The nursing intervention would be to

a. Suggest that the client take the medication in the evening and reevaluate on the next visit.
b. Explain that these are expected side effects and he will have to live with them.
c. Ask the physician to prescribe another antihypertensive.
d. Notify the physician of the negative side effects so the dose can be reduced.

7. A client has the diagnosis of diabetes. His physician has ordered short- and long-acting insulin. When administering two types of insulin, the nurse would

a. Withdraw long-acting insulin, inject air into regular insulin, and withdraw insulin.
b. Withdraw the short-acting insulin into the syringe before the long-acting insulin.
c. Draw up in two separate syringes, then combine into one syringe.
d. Withdraw the long-acting insulin into the syringe before the short-acting insulin.

8. A blood transfusion is started at how many macrodrops per minute, for how long a time?

a. 25 to 50 drops for 15 minutes.
b. 10 drops for 10 minutes.
c. 120 drops for 15 minutes.
d. 20 drops for 10 minutes.

9. A female client with rheumatoid arthritis has been on aspirin gr. xx TID and prednisone 10 mg BID for the last 2 years. The most important assessment question for the nurse to ask related to the client’s drug therapy is whether she has

a. Decreased appetite.
b. Tarry stools.
c. Blurred vision.
d. Headaches.

10. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which is the most important to teach the client before discharge?

a. It is the responsibility of the physician to do the teaching for this medication.
b. He should be sure to take the medication before meals.
c. If he misses a dose, he should double the dose at the next scheduled time.
d. He should shave with an electric razor.

11. A client has the diagnosis of left ventricular failure and a high pulmonary capillary wedge pressure (PCWP). The physician orders dopamine to improve ventricular function. The nurse will know the medication is working if the client’s

a. Cardiac index falls.
b. Blood pressure rises.
c. Blood pressure decreases.
d. PCWP rises.

12. A client in acute renal failure receives an IV infusion of 10 percent dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to

a. Correct the hyperglycemia that occurs with acute renal failure.
b. Provide calories to prevent tissue catabolism and azotemia.
c. Facilitate the intracellular movement of potassium.
d. Force potassium into the cells to prevent arrhythmias.

13. The nurse explains to the client that decreasing dietary oxalate intake can reduce the formation of calcium-oxalate renal stones. The client is prepared to make correct diet choices when he tells the nurse he knows that foods to avoid on such a diet include

a. Rice, potatoes, breads.
b. Carrots, spinach, tomatoes, green beans.
c. Bananas, apples, apricots.
d. Red meats, butter, cheese.

14. A client has just been admitted with a diagnosis of detached retina and surgery is scheduled. The preoperative ophthalmic medication that will most likely be ordered for this client will be

a. Timolol maleate.
b. Atropine sulfate.
c. Carbamylcholine.
d. Pilocarpine.

15. A client with Congestive Heart Failure is placed on several medications including the Beta Blocker Atenolol. The nurse understands that Beta Blockers exert their influence by:

a. Reducing myocardial Oxygen demand
b. Cause vasodilation of coronary vessels
c. Increase heart rate and force of contraction
d. Decrease heart rate and force of contraction

ANSWERS and RATIONALE – Pharmacological and Parenteral Therapies

Click here to view the questions.

1. C. Celiac disease is caused by an intolerance to gluten, which is a protein found in wheat, oats, barley and rye, All the foods in option 3 contain gluten. Option 1 would be eliminated if the child had a lactose intolerance, option 4 would be eliminated if the child had a fat intolerance.

2. D. The most important assessment is vital signs for hemorrhage. The nurse will also check the fundus and for lochia, but the most important is for hemorrhage because it is the most common cause of death in the first hour after delivery.

3. D. Unless the antibiotic is safe for the infant, it is best not to feed the baby, but in order to continue establishment of milk flow, the breasts must be stimulated.

4. A. Exercise, specifically dorsiflexion of the feet, prevents stasis by promoting venous valve and muscle action. Early ambulation, deep breathing and elevating the foot of the bed all increase blood flow. If DVT develops, the client will be placed on bedrest.

5. B. Alzheimer’s disease is a progressive disease that takes years until the patient is completely incapacitated. It is best to support the individuals self esteem by helping them maintain as much control of their life through independent functioning of self care and activities of daily living.

6. C. The physician should be notified immediately. A suspected Wilms’ tumor should never be palpated more than necessary because of the potential for metastasis and should be treated immediately following discovery. It is really not a nursing responsibility to assess for lymph node enlargement.

7. D. Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium.

8. B. The function of the lens is that of accommodation, the focusing of near objects on the retina by the lens; therefore, only the remaining lens will function in this capacity, depending on whether a cataract is present.

9. A. Although abstinence is still the best protection against spread of the HIV virus, the use of a latex condom with a H20 soluble lubricant is the most effective means. All other choices given have no proven validity against the spread of the HIV Virus.

10. B. If the bladder is full, it will push the uterus up out of the pelvis above the umbilicus. The uterus will not contract sufficiently, which could lead to increased bleeding.

11. B. Children with cardiac disease have lowered resistance to upper respiratory infections and should avoid any circumstances that may expose them to even mild infections. Option 1 is unrealistic and option 3 would not put the child at risk since allergies are not contagious, option 4 is wrong because children with cardiac conditions do receive routine immunizations.

12. D. Elevation of the legs promotes circulation and prevents venous stasis and more clot formation. Nursing measures aim at preventing further thrombi from forming and the already present thrombus from detaching. Elastic hose (2) are necessary when the client is up walking again. Placing a pillow under the limb (1) could cause a bend at the groin, with resulting decreased circulation. The client must be kept on bedrest until the danger of emboli passes (4 to 7 days).

13. A. One of the more common problems following Gastric surgery is Dumping Syndrome. Dietary management is the key to reduce or prevent this potential problem from developing. The diet should contain moderate amounts of fat, as well as below in carbohydrates, especially small molecular carbohydrates such as sucrose and glucose. These dietary modifications will result in decreased hypertonicity of the intestinal contents, and prevent osmotic pull of extracellular fluid into the intestinal area, lessening the possibility for Dumping Syndrome to develop.

14. B. While regulating or even touching an IV is definitely not within the scope of behaviors that an NA can legally perform (1), both teaching and clarification of duties is needed in this situation. Before accusing the NA, a nonpunitive environment should be created so teaching of both the LVN and NA can occur, and this action will not happen again. Unless too much medication was given, an incident report does not need to be filled out (2). Confronting the team members in a staff meeting (3) would not be following good management principles.

15. D. Following Total Gastrectomy the production of Intrinsic Factor is permanently destroyed. This is necessary (Intrinsic Factor) for the absorption of Vitamin B12 from the GI tract. As a result patients MUST receive Vitamin B12 by parenteral route throughout life, or a condition known as Pernicious Anemia will develop, and can prove to be fatal. Regular IM injections on a monthly basis of 100-200ug is the usual therapeutic dose.

1. A 4 year old with Celiac Disease is in the hospital with an exacerbation of Celiac Crisis due to improper dietary intake. When teaching the mother the dietary restrictions for her child, which of the following foods must be completely eliminated from the child’s diet?

a. Whole milk, ice cream and cheese
b. Rice, corn and soybeans
c. Bread, oatmeal and pretzels
d. Beef, liver and veal

2. Following delivery of a normal newborn, the nurse will assess the mother every 15 minutes for the first hour. The most important assessment is for

a. Placental fragments.
b. Presence of lochia.
c. Condition of the fundus.
d. Hemorrhage.

3. A breast feeding mother develops mastitis in the left breast and is put on an antibiotic for seven days. She asks the nurse if she can continue breast feeding. The nurse’s best answer would be:

a. “Only breast feed from the right breast.”
b. “Do not breast feed or stimulate the breasts until the infection is resolved.”
c. “Continue breast feeding, this is not a contraindication.”
d. “Pump the breasts and discard the milk until the infection resolves.“

4. The nurse is assigned a client at risk for developing deep vein thrombosis (DVT) following a total knee replacement. The most effective measure to prevent this complication is

a. An exercise schedule of dorsiflexion of the feet.
b. Maintaining a flat bed from the waist down.
c. Instruction in shallow breathing techniques.
d. Maintaining the client on bedrest.

5. An elderly man is admitted to the Geriatric Unit for his forgetfulness and severe behavioral changes. He is diagnosed with Alzheimer’s Disease. Which of the following should be the primary goal of nursing intervention?

a. Keep him away from problems of daily living
b. Keep his capacity for self care activities to the optimum
c. Keep him isolated
d. Keep all available resources to increase his dependency

6. While bathing a 1 year old, the nurse feels a large mass in the abdominal area and notices that his diaper is soiled with pinkish-tinged urine. The initial nursing action is to

a. Gently palpate the abdominal mass to determine if it is a Wilms’ tumor.
b. Continue the assessment by observing his behavior indicating pain on palpation.
c. Immediately notify the physician.
d. Assess if the tumor has spread to the lymph nodes.

7. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?

a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food

8. Instructions given to clients following cataract surgery include the information that

a. Contact lenses will be fitted before discharge from the hospital.
b. They must use only one eye at a time to prevent double vision.
c. They will be able to judge distances without difficulty.
d. The eye patch will be removed in 3 to 4 days, and the eye may be used without difficulty.

9. In teaching High School students about health practices that promote the prevention of spread of the HIV virus, the nurse should include which of the following:

a. Use a latex condom and water soluble lubricant during intercourse
b. Abstain from intercourse if the female is menstruating
c. Following oral intercourse, use an over-the-counter mouthwash so to destroy the HIV virus
d. Shower immediately with an antibacterial soap after intercourse, so to destroy the HIV virus

10. Following delivery of a healthy baby, the nurse completes a postpartum assessment of the new mother. Which of the following symptoms would be indicative of a full bladder?

a. Pulse 52 beats/min.
b. Fundus 2F above umbilicus.
c. Increased uterine contractions.
d. Decreased lochia.

11. The parents of a child with Tetralogy of Fallot have been given discharge instructions. Which of the following situations would the parents be instructed to avoid?

a. All infant contact with persons outside the home
b. Infant contact with persons who have mild colds
c. Infant contact with persons who have severe allergies
d. Routine immunizations

12. A nursing measure to prevent the complication of deep vein thrombophlebitis following surgery would include

a. Wearing elastic hose at all times.
b. Having the client sit up TID.
c. Placing pillows under the affected limb
d. Elevating the foot of the bed.

13. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?

a. Moderate fat, low carbohydrate
b. High fat, high carbohydrate
c. Low fat, low carbohydrate
d. Moderate fat, high carbohydrate

14. The RN observes the nursing assistant (NA) regulating the IV of an oncology client receiving morphine sulfate for pain. An LVN on the RN’s team is responsible for the client and has assigned the client to the NA. The RN’s intervention is to

a. Immediately inform the charge nurse and fill out an incident report.
b. Ask the LVN and the NA to meet with the RN to discuss the responsibility -parameters each of them has.
c. Inform the LVN so that he/she intervenes to instruct the NA that this -action is not within the realm of responsibility of an NA.
d. Call a staff meeting and confront the LVN and the NA.

15. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST be given throughout life:

a. Vitamin C
b. Vitamin B6
c. Vitamin D
d. Vitamin B12

ANSWERS & RATIONALE

These answers are one of the NCLEX prep samples for Reduction of Risk Potential. Click here to view the questions.

1. B. The elevated creatinine level suggests impaired renal function. Assessing intake and output will provide data related to renal function. The other assessments are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and allows the scope to be inserted without trauma.

3. B. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong.

4. A. Urinary tract infections in the elderly often present as urinary incontinence that develops suddenly. Renal failure (1) and fluid volume excess (3) typically are characterized by oliguria. Dementia (4) develops slowly and is manifested by disordered thinking and behavior.

5. D. The most important safety measure is to tape a hemostat nearby to use in case of an air leak. Chest tubes should be checked periodically, but not necessarily every 2 hours (2). The client should be in semi-Fowler’s position to increase lung expansion.

6. C. There is an increased incidence of hemorrhaging with the external cannula. Hemorrhage results from the cannula becoming disconnected. One advantage of the external cannula is that it is painless to use. Surgery is required to establish the internal fistula and it should be allowed to heal for several weeks before being utilized.

7. A. The rope/pulley and weight system is arranged so that fracture fragments are in the desired approximate position for healing. The client’s position should always rest in line with the traction pull. The line of pull must never be interfered with by changing the position of a pulley and extension bar.

8. A. Russell’s traction is a type of skin traction that incorporates a sling under the knee that is connected by a rope to an overhead bar pulley. It is frequently used to treat femoral shaft fractures in the adolescent.

9. D. Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.

10. B. The collection bag must be able to fill easily; therefore, it needs to be distended. The bag must be vented with a filter so that urine can be drained from the chamber. The tube must not be allowed to coil or become kinked above the level of the bladder. The collection bag is positioned below the level of the bladder to allow for continuous urine drainage and prevent urine backflow into the bladder. In order to prevent reflux of urine, the tubing must be of sufficient length, usually 5 feet.

11. B. Because more weight can be applied with skeletal traction, it can be used to reduce fractures and maintain alignment. It is not used commonly in the elderly because of prolonged immobilization. It is not preferred for children because some displacement of fracture fragments is desirable to prevent growth disturbance. Frequently, clients have more mobility than they do with skin traction, because balanced suspension is often incorporated with skeletal traction.

12. C. Diabetes insipidus is an antidiuretic deficiency and may occur following brain surgery or head injury. It also occurs in young adults resulting from damage to the posterior lobe of the pituitary gland. Severe polyuria occurs when there is an inability to concentrate urine. These are not symptoms of types 1 and 2 diabetes (2, 3) or Addison’s disease (4) (which is adrenocorticol hypofunction).

13. D. Preventing cerebral trauma during the convulsion is a priority activity. Placing some form of padding under the head will protect the skull and brain from injury. Inserting a mouth gag (1) and restraining the limbs (3) are unsafe interventions. The nurse would not leave a seizing person to go and obtain equipment (4).

14. D. The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

15. A. Putting pressure over the vessels in the neck may be lifesaving because a severe blood loss can occur rapidly, leading to shock and death. The surgeon would be notified as soon as possible.