NCLEX Practice Questions — Set 29
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A client is admitted to a medical-surgical unit with an infection of the right great toe and temperature of 38.9�C (102�F). The client appears to be becoming psychotic. In determining what action to take next, which of the following factors should the nurse consider?
Show answer and rationale
Correct answer: C. The client is psychotic because of the infection
An infection may contribute to a client’s distortion of perceptual reality. Dementia does not have an acute onset. There is no evidence that the client had a seizure. It is unlikely that an infection would make someone psychotic.
A client with a bipolar disorder is brought to the emergency department by the spouse after the client pointed a steak knife at the spouse and yelled, "I know that you are jealous of my special gifts from God!" The nurse informs the spouse that this behavior is most likely explained by which of the following? The client
Show answer and rationale
Correct answer: D. became psychotic during a manic phase.
A client may become psychotic during a manic phase of a bipolar disorder. Not handling marital discord and wanting to kill one’s spouse do not most likely correlate with a manic episode. Dementia has a slow onset and usually appears in an older client.
The wife of a client with paranoid personality disorder asks the nurse why the client keeps blaming her for plotting against him. Which of the following is the appropriate response by the nurse?
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Correct answer: A. "A client with paranoid personality disorder suspects others’ motives."
Suspicion of others is a hallmark of paranoid personality disorder. Preferring solitary activities, lacking interest in hobbies or other interests, and becoming emotionally detached are all clinical manifestations of an individual with schizoid personality disorder.
A client diagnosed with paranoid personality disorder has been hospitalized because of his suspicions and threats toward the company boss. While in the hospital, the client continues to be suspicious of the nursing staff. The primary goal for this client would be which of the following?
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Correct answer: D. Promote the development of trust with the nursing staff
Promoting the development of trust with the nursing staff is the best goal for a client who is experiencing paranoia. This will support and encourage the client to make better progress in treatment and begin to trust the staff.
Two staff members are talking and laughing about their weekend activities in the hall outside the room of a client diagnosed with paranoid personality disorder. The client appears annoyed and is suspicious of them while they are talking. Which of the following is the most appropriate intervention?
Show answer and rationale
Correct answer: D. Inform the staff members that the talking can be misinterpreted as secretiveness
Behavior that can be interpreted as secretive by a client who is paranoid will reinforce the client’s feelings of suspiciousness. A client who is paranoid may interpret seeing two staff members talking outside the client’s room as being secretive.
An important role of the nurse is to facilitate social interactions between a client who is paranoid and the client’s peers. The nurse implements this intervention based on the understanding that a client with paranoid personality disorder
Show answer and rationale
Correct answer: D. tends to be isolated and lacks social skills.
A client with paranoid personality disorder often becomes socially isolated because of suspiciousness toward others. This client would not be gregarious or outgoing. Such clients do not feel that they have a problem. A client who suffers from paranoia would not have social skills that would be enhanced by being around or sharing with others.
When planning the care of a client who is paranoid, the nurse should include which of the following interventions to increase the sense of trust?
Show answer and rationale
Correct answer: A. Solicit the client’s participation in the development of the treatment plan
Soliciting a client’s participation in the development of the treatment plan is an effective way to get a client who is paranoid to improve communication and participation in the treatment plan and to develop a trusting relationship. Giving a client a home phone number or spending more time with this client than with other clients violates professional boundaries. Fulfilling all of the client’s requests can cause the client to become more suspicious.
Which of the following interventions would be most appropriate for the nurse to implement for a client in a paranoid state who is having difficulty falling asleep and has tried reading, taking a warm bath, and drinking warm milk, all of which have been unsuccessful?
Show answer and rationale
Correct answer: B. Administer a prescribed drug for relaxation
After unsuccessful attempts to sleep, as evidenced by reading, drinking milk, or taking a warm bath, the next appropriate intervention would be to offer a prescribed drug for relaxation. It would be inappropriate to instruct the client to try these measures for a longer time period, to give the client a back rub, or to encourage the client to listen to the radio because the client has already tried nondrugrelated measures and continues to be frustrated.
A client experiencing paranoid behavior believes that the drugs are poisonous and doesn’t want to take them. Which of the following nursing interventions should the nurse include in this client’s plan of care?
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Correct answer: B. Tell the client that taking the drugs are a part of the treatment
The most appropriate intervention for a client who thinks the drugs are poisonous is to be direct with the client and tell the client that the drugs are an important part of the treatment. Forcing the client to take the drugs, restricting the client to the room until the drugs are taken, or informing the client that the doctor ordered the drugs would not work, because this is a suspicious client who will not respond to reason.
Which of the following does the nurse evaluate as a disturbance in the activities of daily living for a client who is paranoid? The client
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Correct answer: A. refuses to eat any food item that is not prepackaged and can be self-opened.
A disturbance in the activities of daily living for a client who is paranoid is to refuse to eat any food that is not prepackaged and can be self-opened. A client with paranoia would not sign up for Meals on Wheels or go to a neighbor’s house for dinner because the client did not prepare the food and may believe it is contaminated. Going to the grocery store when more food is needed is not an impairment to the activities of daily living.
A client who has been diagnosed with paranoid delusions frequently takes issues to the legal system, resulting in court hearings. This is most likely due to the fact that
Show answer and rationale
Correct answer: D. the client initiates legal action due to the persecutory content of the delusions.
A client with persecutory delusions frequently initiates legal action because of the belief that others are attacking him. It is through the court actions that the client attempts to remedy these beliefs about the other individuals. Other individuals taking the client to court because of the client’s poor decisions is focusing on the thoughts and actions of someone other than the client. The client being taken advantage of also focuses on the other individual’s thoughts and actions, rather than the client’s. A client with persecutory delusions is not trying to get attention; instead, the issue is about rectification for the perceived wrongs done to the client.
A client who has paranoid delusional disorder has been having spousal difficulties but is making good progress at work during this quarter. The nurse identifies which of the following as the most likely cause of the client’s behavior?
Show answer and rationale
Correct answer: C. The client’s delusions mainly affect relationships
Clients with delusional disorders can generally function adequately when they do not focus on their delusional belief system, which usually affects social and marital relationships. Because of this, the client would be able to manage adequately in the work environment.
A client who has been diagnosed with paranoid delusional disorder is developing healthier interpersonal relationships. During this development, the nurse encourages the client to
Show answer and rationale
Correct answer: C. identify people with whom it is safe to talk.
Establishment of trust and a safe relationship is important and difficult for the client who has paranoid delusions. Talking about the client’s delusions whenever they occur, remembering the paranoid thoughts until the next therapy session, and seeking feedback regarding the realistic nature of the delusion all focus on the delusional thoughts.
A client is diagnosed with paranoid schizophrenia and has been hospitalized due to auditory hallucinations resulting in verbal threats. These hallucinations are of a persecutory nature. Which of the following is the most appropriate nursing diagnosis?
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Correct answer: D. Sensory perception, disturbed
Hallucinations are, by definition, perceptual distortions and are not the result of deliberate choices. Therefore, the most appropriate nursing diagnosis is disturbed sensory perception. Nursing diagnoses of Noncompliance, Ineffective health maintenance, and Disturbed personal identity would all involve deliberate choices.
A nurse teaching a class on paranoid personality disorder correctly describes the client as appearing angry and argumentative, but in reality the client feels
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Correct answer: A. vulnerable and powerless.
Clients who have paranoid personality disorder use denial and projection as their main defense mechanisms, because in reality they feel vulnerable and powerless. Shy, awkward, depressed, suicidal, secure, and confident may co-occur with paranoia, although they do not explain the projection of insecurity into anger.
A client is being evaluated for headaches and paranoid delusions. A computerized tomography (CT) scan reveals a brain tumor. The diagnosis of paranoid delusional disorder is in question at this point because the
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Correct answer: B. clinical manifestations present along with a medical condition.
Medical issues must be diagnosed and evaluated as a potential cause of clinical manifestations that may also appear psychiatric in nature.
A client with paranoid schizophrenia has been seeing a public health nurse every week for drug administration and compliance. The current drugs have been effective in decreasing positive clinical manifestations. The nurse anticipates that the client will report
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Correct answer: D. a week without hearing voices.
A client who reports a week without hearing voices demonstrates a decrease in positive clinical manifestations. Lack of motivation is a negative clinical manifestation, and a decrease in the motivation to go to church would indicate no improvement in the client’s condition. A client who sees his dead grandmother is having a positive clinical manifestation, clearly demonstrating that the client is still in the throes of paranoid schizophrenia. More social activities is a negative clinical manifestation, indicating an improvement in the client’s condition.
The registered nurse is preparing to delegate nursing tasks to a licensed practical nurse. Which of the following tasks should the nurse delegate to a licensed practical nurse?
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Correct answer: A. Document a client’s paranoid behavior
Nursing tasks that involve the skills of evaluating, assessing, and instructing are reserved for the registered nurse. A licensed practical nurse may document a client’s paranoid behavior.
Which of the following is a priority goal for the nurse to plan in the care of a client who experiences paranoid delusions?
Show answer and rationale
Correct answer: A. Establishment of trust
As with many psychiatric disorders, establishing trust is paramount to the success of the nurse-client therapeutic relationship.
A client who suffers from paranoid delusions utilizes denial as a defense mechanism. The nurse wants to foster other ways of dealing with the anxiety that the client experiences. The nurse could best do this by planning for the client to be involved in which of the following activities?
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Correct answer: D. Individualized relaxation therapy
A client with paranoid delusions is most likely to deal with the anxiety in situations by getting involved in relaxation therapy. Attempting to get clients involved in group therapy or an education class would foster further paranoia because of the group environment.
A client who has been diagnosed with paranoid delusional disorder is getting ready for an evening discharge. This client has a history of expressing anger by threatening to hurt family members with household objects. In preparation for discharge, the nurse should instruct the family that which of the following is a priority if the client becomes threatening?
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Correct answer: D. Remove any potential weapons from the home
The first action to take when discharging a client who in the past threatened to hurt family members with household items would be to remove any potential weapons from the home. It would not be appropriate to wait to call the health care provider in the morning because the call is too delayed. It would not be particularly helpful for an agitated client to go to a quiet room to cool down. The client should not be unsupervised. Although an extra dose of a drug may be administered, it is not the priority.
In preparation for practicing new coping skills, the nurse assists the client with paranoia in
Show answer and rationale
Correct answer: A. identifying personal manifestations of anxiety.
Before planning interventions for new coping skills for a client, the nurse needs to consider the client’s manifestations of anxiety. Anxiety is a common emotion with paranoia. Asking the physician for other coping methods, copying other clients’ techniques, and reading books all focus on sources other than the client. The focus should be on the client and the client’s needs.
A client has been experiencing irritability, difficulty concentrating, difficulty sleeping, and withdrawal for the past 8 weeks since her house burned to the ground after an explosion. The nurse assesses that this client is experiencing
Show answer and rationale
Correct answer: A. post-traumatic stress disorder.
Clients may experience clinical manifestations of post-traumatic stress disorder after experiencing a traumatic event, such as a house burning down. Clinical manifestations need to be present for at least 1�month for a diagnosis of post-traumatic stress disorder. The client’s clinical manifestations begin abruptly after a traumatic event and last for a period greater than a month.
A client recently started on a monoamine oxidase inhibitor (MAOI) is experiencing severe headache, tachycardia, and cold, clammy skin. Which of the following is the priority nursing intervention?
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Correct answer: C. Assess the client’s blood pressure
A toxic and serious adverse reaction to MAOIs is a hypertensive crisis. Clinical manifestations of a hypertensive crisis include severe headache, tachycardia, hypertension, and cold, clammy skin. The nurse’s priority would be to assess for an increase in blood pressure. A hypertensive crisis can begin abruptly after taking a contraindicated food or drug. Immediate medical intervention is indicated when a hypertensive crisis is suspected. It is only after assessing the blood pressure and confirming the diagnosis that interventions can begin.
The nurse assesses which of the following clients to be at the highest risk of developing post-traumatic stress disorder?
Show answer and rationale
Correct answer: A. A client who witnessed a fatal shooting
Experiencing a traumatic event such as a shooting is an event likely to trigger a posttraumatic stress disorder in a person.
A client reports experiencing nightmares and constant worry about the weather since a tornado destroyed the client’s house 1�year ago. The nurse assesses that this client is experiencing
Show answer and rationale
Correct answer: D. flashbacks.
A client who repeatedly experiences nightmares and constantly worries about the weather since a tornado destroyed the client’s house 1�year ago is experiencing flashbacks. Clients who have flashbacks have recurrent intrusive recollections of the traumatic event. Clients with delusions, hallucinations, and panic attacks would not reexperience the traumatic event in this way.
A client scheduled to begin relaxation therapy as part of treatment for post-traumatic stress disorder asks the nurse what the purpose is of the relaxation therapy. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: C. "It will help produce effects that are the opposite of those produced by anxiety."
Relaxation therapy helps the client learn ways to relax the body and reduce the tension produced by anxiety. Relaxation therapy does not guarantee that the client will not be frightened anymore. Helping a client learn about personal illness is the definition of psychoeducation. Helping the client learn calming self-talk defines cognitive restructuring.
When planning the care of a client who is experiencing post-traumatic stress disorder, the nurse identifies which of the following as an appropriate goal? The client will report
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Correct answer: D. a decrease in flashbacks and nightmares.
The target clinical manifestation for a client with post-traumatic stress disorder is flashbacks. Ritualistic behavior is associated with obsessive-compulsive disorder. Having a decreased energy level is associated with depression. Hearing voices is associated with schizophrenia.
A client tearfully reports having been sexually attacked by a spouse during an argument. The nurse evaluates this situation as
Show answer and rationale
Correct answer: B. a rape because sex against one’s will is rape.
Acquaintance rape and marital rape are currently recognized by the court system. The current law allows a person to bring charges against a spouse for rape. Awareness continues to be raised that women are individuals with rights and privileges and not property.
During an interview, the nurse observes a client becoming increasingly defensive. The client states, "You wouldn’t understand what I’ve been through." Which of the following is the most appropriate response by the nurse?
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Correct answer: D. "Sometimes it feels like no one else can understand, but I would like to try."
Frequently, clients have experienced things that the nurse has not. By using therapeutic communication skills such as reflecting and empathizing, the nurse can encourage the client to share experiences and begin to understand and develop a therapeutic relationship.
Which of the following should the nurse include when teaching a class on recognizing post-traumatic stress in children?
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Correct answer: A. Children and adolescents can develop clinical manifestations of post-traumatic stress disorder after experiencing any traumatic event
Many children and adolescents have experienced natural and man-made disasters in their lives, such as kidnapping, rape, school shootings, peer suicides, fires, and floods. Clinical manifestations of post-traumatic stress disorder may develop in children and adolescents after experiencing these types of traumatic events.
A client currently taking fluoxetine (Prozac) to decrease clinical manifestations of posttraumatic stress disorder asks the nurse if continuing to take dietary supplements such as Saint John’s wort, ginseng, and kava kava is acceptable. The most appropriate response by the nurse is which of the following?
Show answer and rationale
Correct answer: D. "Dietary supplements may interact negatively with your prescribed drugs; check with your care provider."
Current studies have shown that dietary supplements may have beneficial uses in decreasing clinical manifestations of mild depression, anxiety, and insomnia when not used in conjunction with prescription drugs. Dietary supplements are not controlled by the Food and Drug Administration (FDA). Studies have shown that taking dietary supplements along with prescription drugs may cause adverse reactions. The client should be encouraged to discuss the amount and type of supplements being taken with the person who is prescribing the drugs.
The registered nurse is preparing the clinical assignments for team members on a psychiatric unit. Which of the following assignments indicates that the nurse has appropriately delegated assignments?
Show answer and rationale
Correct answer: B. Unlicensed assistive personnel sit with a client who is tearful
Unlicensed assistive personnel may sit with a client who is tearful. A licensed practical nurse should not perform the skills of assessing a client or developing a plan of care. These are tasks reserved for the registered nurse. It is not appropriate for unlicensed assistive personnel to attend group therapy with a client.
Which of the following nursing interventions is a priority when planning nursing care for the client experiencing alcohol withdrawal?
Show answer and rationale
Correct answer: B. Administer a benzodiazepine
Because alcohol is a central nervous system (CNS) depressant, withdrawal will cause the client’s CNS to be activated. Administering a benzodiazepine takes priority when caring for a client experiencing alcohol withdrawal. It will lower blood pressure and pulse, decrease anxiety, and assist in preventing seizures and death. Encouraging fluids, providing three well-balanced meals, and teaching techniques to reduce anxiety are all appropriate interventions but are not the priority.
Which of the following orders should the nurse question when planning the nursing care for a client beginning to experience alcohol withdrawal?
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Correct answer: D. Nothing by mouth
Fluids should be encouraged for clients experiencing alcohol withdrawal because they often experience dehydration. Fluids would never be withheld. Assessing vital signs, teaching relaxation techniques, and avoiding caffeine in the diet are all appropriate nursing interventions for a client in alcohol withdrawal.
Which of the following would provide the nurse with the most beneficial assessment data on alcohol abuse?
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Correct answer: A. The CAGE questionnaire
A complete blood cell count and a chemistry panel will assist the nurse in identifying medical issues that may be caused by alcohol abuse, but these tests alone will not reveal the information needed to assess for the alcohol abuse. The CAGE questionnaire is the acronym for assessing clients for alcohol abuse. The Beck Depression Inventory assesses a client’s severity of depression.
The priority nursing intervention in caring for a client experiencing flashbacks from hallucinogenic intoxication is which of the following?
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Correct answer: D. Assisting the client with reduction of anxiety
Although exploring with the client what triggers a relapse, providing intrapersonal skills, and teaching the client the medical consequences of hallucinogens are important interventions in a client experiencing hallucinogenic intoxication, they are not the priority. Reducing stimuli and the client’s anxiety are the priority nursing intervention for a client experiencing flashbacks from hallucinogen intoxication.
The nurse is caring for a client who drank large amounts of alcohol for more than 2�years and abruptly stopped drinking alcohol 30�hours ago. Which of the following nursing measures should receive priority in this client’s plan of care?
Show answer and rationale
Correct answer: C. Monitor vital signs frequently
Although performing a cranial nerve assessment, providing adequate nutrition, and encouraging fluids are all appropriate interventions, monitoring vital signs is the priority intervention. Monitoring the vital signs frequently will determine when the client goes into alcohol withdrawal.
The nurse is asked to teach a class to a group of clients in a drug rehabilitation clinic on the medical complications of cocaine abuse. Which of the following complications should the nurse include in the class?
Show answer and rationale
Correct answer: B. Cardiac arrhythmias
Cocaine is a stimulant that works directly on the central nervous system and produces cardiac arrhythmias. Cardiac arrhythmias can lead to death for a client who abuses cocaine. Hypertension is a complication that occurs with toxic levels of cocaine. Constipation does not occur as a result of cocaine; it is actually diarrhea that occurs. Kidney failure is also not a complication of cocaine use.
A client repeatedly returns to the hospital with an unsteady gait and slurred speech after several failed inpatient treatment attempts for alcohol dependence. Which of the following nursing interventions is appropriate for the nurse to implement for this client?
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Correct answer: D. Promote safety and transition to the hospital
A client who has an unsteady gait and slurred speech after several failed attempts at treatment for alcohol dependence is experiencing alcohol intoxication. Promoting safety and facilitating transition to the hospital is the appropriate intervention for this client. Administering a benzodiazepine, a barbiturate, or a narcotic would actually depress the central nervous system even further and is contraindicated. Increasing protein in the diet is not a standard intervention to be implemented for a client experiencing alcohol intoxication.
A client presents to the emergency room complaining of trails of images, moving objects, and flashes of color. The nurse notifies the physician that the client has been abusing which substance?
Show answer and rationale
Correct answer: D. Hallucinogens
The perceptual disturbances of experiencing trails of images, halos, and flashes of color occur with hallucinogen use.
Which of the following should the nurse include when preparing to teach a nicotinecessation program?
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Correct answer: A. Decreased psychomotor performance, mental dullness, and decreased judgment may be experienced by the client
A decrease in psychomotor performance, mental dullness, and decreased judgment are experienced by the client in a nicotinecessation program. Hot flashes, decreased appetite, and muscle cramps are not associated with nicotine withdrawal. Nicotine withdrawal lasts several weeks to months. The nurse should keep the focus of the class professional and on educating the participants of the nicotine withdrawal class and not on personal experiences.
The nurse is preparing to teach a class to a group of new graduate nurses on substance use disorders. Which of the following should the nurse include in the class?
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Correct answer: D. Substance abuse is both a physical and psychological disorder
A substance use disorder is both physical and psychological. A client with substance dependence can take a similar substance to relieve withdrawal clinical manifestations. A client cannot overcome a substance use disorder simply by being motivated and stopping the substance. Management of substance use disorders must include professional intervention. Generally, the most effective treatments are in mental health clinics that can provide both physical and psychological assistance.
The registered nurse is preparing the clinical assignments for a psychiatric unit. Which of the following assignments is appropriate for the nurse to delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: A. Provide a safe environment for a client with alcohol dependence
A licensed practical nurse may provide a safe environment for a client with alcohol dependence. Assessing, instructing, and reporting are all skills reserved for a registered nurse.
The nurse is admitting a client who has been abusing phencyclidine (PCP) for several months. In planning this client’s care, which of the following should be the priority?
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Correct answer: C. Ensure the safety of the client
A client who has been abusing PCP experiences distorted perceptions, hallucinations, and delusions that may result in the client becoming violent. Ensuring the client’s safety is the priority. The client has the potential to hurt himself or others. Eating a well-balanced diet, instructing the client on the medical complications of PCP use, and encouraging participation in a withdrawal program are all appropriate interventions, but they are not the priority.
A client who is seeing "pink elephants on the wall," hearing voices, constantly picking at the face and hands, and stating "people are out to kill me" and who has a blood pressure of 168/90 is admitted. The nurse assesses this client to be experiencing which of the following?
Show answer and rationale
Correct answer: B. Amphetamine toxicity
A client who has a toxic level of amphetamines experiences hallucinations (auditory, visual, and tactile), severe paranoia, picking at the face and extremities, and hypertension.
A mother brings her adolescent son into a clinic and expresses concerns that the son has been experiencing blurred vision, dizziness, a sense of well-being, and slurred speech. Which of the following questions is a priority for the nurse to ask?
Show answer and rationale
Correct answer: D. "Have you noticed your son inhaling paint and cleaning or aerosol products?"
The priority question to ask the mother of a child suspected of inhaling substances is if she has noticed the child inhaling paint or cleaning or aerosol products.
Which of the following findings would provide the nurse with the most accurate information regarding a client with sexual aversion disorder?
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Correct answer: A. Marked distress in interpersonal functioning
Marked distress in interpersonal functioning is a criterion for the diagnosis of sexual aversion disorder. Substance abuse alone can cause sexual dysfunction; however, it does not meet the criteria for sexual aversion disorder. Avoidance, rather than preoccupation, with sexual encounters is a characteristic. Frustration, instead of gratification, is seen with sexual aversion disorder.
The nurse should instruct a client with a sexual dysfunction about drugs that have a pharmacologic influence on sexual functioning. Which of the following drugs impact sexual functioning and should be included in this discussion?
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Correct answer: C. Antidepressants
Antidepressants have a direct effect on sexual performance and result in loss of libido. Antibiotics, analgesics, and anti-inflammatories do not have an effect on sexual functioning.
A client with orgasmic disorder may have contributing hormonal problems. The nurse should counsel the client that which of the following factors may contribute to the disorder?
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Correct answer: D. Normal aging
Normal aging can contribute to the slowing of an orgasm in orgasmic disorder. Exercise is not a factor in orgasmic disorder. Decreases in testosterone may contribute to orgasmic disorder. Increase in prolactin may contribute to orgasmic disorders.
The nurse is collecting a nursing history from a client admitted with a sexual dysfunction. Which of the following questions is a priority for the nurse to ask?
Show answer and rationale
Correct answer: D. "Do you have anxiety about sexual performance?"
Anxiety is the factor that most dramatically affects sexual dysfunction, so it would be a priority to ask if the client has anxiety about sexual performance. The client’s age, drugs that the client takes, and the client’s exercise regime may contribute to a sexual dysfunction but do not qualify as the priority.
The nurse is teaching a client with a sexual dysfunction. Which of the following elements would be the most critical for the nurse to teach the client about the disorder?
Show answer and rationale
Correct answer: C. Mutual respect between partners is crucial
Establishing mutual respect is critical between partners being treated for sexual dysfunctions. Preferences of gender do not contribute to sexual dysfunctions. Drugs may precipitate sexual dysfunctions, but they are not the priority. Power struggles between partners do contribute to sexual dysfunctions.
Which of the following assessments would provide the nurse with the most accurate information regarding a client with gender identity disorder? Assess and evaluate if the client
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Correct answer: B. had an early feeling of being trapped in the wrong gender.
An early feeling of being trapped in the wrong gender is the diagnostic criterion for establishing the diagnosis of gender identity disorder. The sexual preference of the individual does not contribute to the disorder. The client’s history of abuse also is not a diagnostic criterion for the disorder. Aversion to individuals who are of the same sex is also not a criterion for gender identity disorder.
The nurse assessing a client with the diagnosis of voyeurism should note which of the following characteristics?
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Correct answer: D. Peeping becomes compulsive
Voyeurism is a sexual disorder that involves watching others while they disrobe, are naked, or are engaging in various sexual acts. Peeping becomes compulsive and is preferable to other sexual activities. The individual is usually heterosexual, unskilled, and socially shy. Such individuals usually have few close friends.
Which of the following assessments would provide the nurse with the most accurate information about a client with transvestitism?
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Correct answer: C. Develops early in life
Transvestitism is a disorder that involves cross dressing or fantasies about cross dressing. It develops early in life. There is no desire for a sex change or for a change in the client’s sexual orientation.
The nurse treating a client with paraphilia would include which of the following in the care plan?
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Correct answer: C. Combination therapy
The recommended treatment for paraphilia is a combination of therapies. Alternative medicine and residential treatment are not recommended. Therapy should be conducted over an extended period of time.
The nurse treating a client with sexual addictions should assess for which of the following clinical manifestations when formulating the nursing assessment?
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Correct answer: C. Patterns of unsuccessful love relationships
Patterns of unsuccessful love relationships are diagnostic for sexual addictions. The client is bewildered by personal behavior. The client feels a need to escape after sex and is compelled to have frequent sex.
The nurse planning care for the client with a sexual addiction understands that the client is at risk for sexually transmitted disease. What is a priority to include in this client’s care plan?
Show answer and rationale
Correct answer: D. Educate the client about safe sex
Educate the client about safe sex. The priority intervention when working with a client who has a sexual addiction is to educate the client about safe sex practice. It is imperative to inform the client about the use of condoms and dental dams and the avoidance of multiple partners. The focus of nursing care should be holistic and preventive rather than disease oriented.
The nurse evaluates which of the following disorders to contribute to the severity of a sexual disorder?
Show answer and rationale
Correct answer: D. Diabetes
Diabetes is a physical illness that interferes with sexual functioning. Schizophrenia, bipolar disorder, and anorexia do not contribute to the severity of a sexual disorder.
The nurse planning for the discharge of a client with sexual dysfunction would take into consideration which of the following measures?
Show answer and rationale
Correct answer: C. The client’s judgment may be clouded by perceptual defenses
The judgment of a client with a sexual dysfunction may be clouded by perceptual as well as intellectual defenses. The client will need to develop trusting relationships. Recovery is contingent on nonjudgmental thoughts by the nurse and partner. Power struggles with the partner are to be avoided so that recovery can occur.
The most effective treatment tool the nurse should use when working with a client with sexual disorders is
Show answer and rationale
Correct answer: A. the complete general history.
The complete general history is crucial to treatment of the whole individual dealing with a sexual disorder. The sexual disorders history will not give clues into underlying or contributing factors. Drug management is not as important as understanding of the whole person. Family therapy alone will not give a full picture.
When working with a client with hypoactive sexual desire disorder, the nurse should include which of the following recommendations in the treatment plan?
Show answer and rationale
Correct answer: C. Establish a therapeutic alliance
The most important treatment strategy in working with a client who has hypoactive sexual desire is the establishment of a therapeutic alliance. Substance abuse precludes the client from meeting diagnostic criteria. The existence of a medical condition also precludes the diagnosis of hypoactive sexual disorder. Focusing on the disorder increases anxiety and may exacerbate the clinical manifestations.
The nurse planning the treatment for a client with aversion disorder considers which of the following in the care plan?
Show answer and rationale
Correct answer: A. Anxiety and disgust contribute to distress
Anxiety, disgust, or fear concerning the sexual encounter contributes to extreme psychological distress in a client with aversion disorder. The existence of a medical condition does not meet the diagnostic category. Interpersonal functioning is critical for the remission of the disorder. Aversion and avoidance are classic criteria.
The nurse developing a treatment plan for a client with gender identity disorder would include which of the following measures?
Show answer and rationale
Correct answer: D. Short-term therapy
Discharge from the genitals is a clinical manifestation of chlamydia. General body aches is not a clinical manifestation. Persistent burning on urination is a clinical manifestation. Treatment involves antibiotics and there is no spontaneous remission.
Which of the following clinical manifestations would the nurse assess as most prevalent in a client suspected of having contracted chlamydia?
Show answer and rationale
Correct answer: B. Discharge from the genitals
Discharge from the genitals is a clinical manifestation of chlamydia. General body aches is not a clinical manifestation. Persistent burning on urination is a clinical manifestation. Treatment involves antibiotics and there is no spontaneous remission.
When assessing a client suspected of having hepatitis B, which of the following clinical manifestations supports the diagnosis?
Show answer and rationale
Correct answer: B. Unprotected sexual contact
Unprotected sexual contact is a route for hepatitis B. Malnutrition does not contribute to hepatitis B. The fecal-oral route relates to hepatitis A. Clients with sexual addiction may or may not contract hepatitis B.
The registered nurse is preparing clinical assignments for a psychiatric unit. Which of the following clinical assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: C. Document the behavior exhibited by a client with gender identity disorder
Documenting the behavior exhibited by a client with gender identity disorder may be delegated to a licensed practical nurse. Performing a complete general history, assessing a client, and developing a plan of care are all assignments that should be performed by a registered nurse.
The nurse is teaching a class on eating disorders to a group of nurses. Which of the following should the nurse include in the class?
Show answer and rationale
Correct answer: A. There is an increased incidence of depression in clients with eating disorders
Although the incidence of eating disorders is increasing in male clients, the incidence is much higher in females. There is an increased incidence of depression found in clients with eating disorders. Dysthymias or major depressive episodes have a 50-75% incidence. There is a theory of a possible mother-daughter connection.
The nurse should administer which of the following drugs to a client with an eating disorder who has a delayed gastric emptying time?
Show answer and rationale
Correct answer: D. Metoclopramide (Reglan)
Esomeprazole (Nexium) is a proton pump inhibitor used in the short-term management of gastroesophageal reflux (GERD). Metoclopramide (Reglan) is a gastrointestinal stimulant used in the treatment of delayed gastric emptying and gastroesophageal reflux. Dicyclomine (Bentyl) is a cholinergic-blocking drug used in the treatment of hypermotility and spasms of the gastrointestinal tract associated with irritable colon and spastic colon. Diphenoxylate with atropine sulfate (Lomotil) is an antidiarrheal used in the management of diarrhea.
The nurse is planning the care for a client with muscle weakness, constipation, a serum potassium of 3.0 mEq/L, and a pulse of 65 bpm. What clinical manifestation should take priority in this client’s plan of care?
Show answer and rationale
Correct answer: D. Serum potassium 3.0 mEq/L
Although a client with an eating disorder may have muscle weakness, constipation, and bradycardia, it is the serum potassium of 3.0 mEq/L that should be the priority. Generally, a client with a serum potassium level of 3.0 mEq/L would be hospitalized. Severe hypokalemia may lead to dysrhythmias and subsequent death. Normal potassium is 3.5 to 5.5 mEq/L.
The nurse administers which of the following prescribed drugs to a client with anorexia nervosa for the purpose of improving weight gain?
Show answer and rationale
Correct answer: C. Fluoxetine (Prozac)
Olanzapine (Zyprexa) is an antipsychotic used in the management of anorexia nervosa to enhance compliance with treatment and decrease agitation. Sertraline (Zoloft) is a selective serotonin reuptake inhibitor used to decrease binge episodes in clients with a bingeeating disorder (obesity). Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor used to improve weight gain in the client with anorexia nervosa. Quetiapine (Seroquel) is an antipsychotic used in the treatment of schizophrenia.
Which of the following statements would provide the nurse with the most accurate information regarding how successful the treatment has been for a client with a longstanding history of bulimia?
Show answer and rationale
Correct answer: C. "I have learned to eat a variety of foods."
A client who has bulimia and is able to verbalize eating a variety of foods is showing success with treatment. Eating a variety of foods indicates that the client does not consider some foods as "forbidden foods" and understands that the key to success is proportion. A client should not take prescribed medicine only when responding to an urge to binge; medicine must be taken regularly until the therapist deems it is no longer necessary. Trying to do other things when feeling the urge to binge is a positive step, but it does not indicate success. A client cannot merely try to do other things when feeling the desire to eat. Success would be measured in being successful doing other tasks instead of eating. It is not a positive step for a client to say there is no longer a need to see the therapist. Seeing the therapist should be a regular commitment and not a capricious phenomenon.
The nurse is collecting data on an 11-year-old client suspected of having anorexia nervosa. Which of the following physical assessment findings should be reported to the client’s physician confirming the presence of anorexia nervosa?
Show answer and rationale
Correct answer: C. The presence of lanugo
A client with anorexia nervosa generally will exhibit hypothermia, bradycardia, lanugo, and amenorrhea. However, an 11-year-old client with anorexia nervosa may have not started menses and certainly has not had menses long enough to establish a pattern.
During an admission interview, a client with anorexia nervosa complains of feeling cold all the time and asks the nurse why. Which of the following is the most appropriate response by the nurse?
Show answer and rationale
Correct answer: A. "There is a loss of subcutaneous fat."
Clients who have a history of anorexia frequently complain of feeling cold all the time that is unrelated to weather and clothing. Hypothermia is the result of dehydration or a loss of subcutaneous tissue.
The nurse is interviewing a 46-year-old female client with a binge-eating disorder who is tearful and admits to the nurse of being depressed. The client states, "I have been fat all my life and I can’t lose weight." Which of the following should be the priority response by the nurse?
Show answer and rationale
Correct answer: B. "Cognitive behavioral therapy offers the most success."
Although a client with a binge-eating disorder needs to stop binging and eat a well-balanced diet, the best chance for recovery from a bingeeating disorder is cognitive behavioral therapy. Sertraline (Zoloft) is a selective reuptake inhibitor used in binge-eating disorders for the purpose of decreasing the binge episodes.
The registered nurse is delegating clinical assignments on an eating disorder unit for the day. Which of the following clinical assignments would be appropriate for the nurse to delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: B. Monitor a client with an eating disorder after meals
It would be acceptable to delegate monitoring a client with an eating disorder after meals. Only a registered nurse can develop, create, and instruct a client.
A client with anorexia nervosa is crying and tells the nurse, "I just want to die. I can’t live like this anymore." In determining what action to take next, which of the following factors is a priority for the nurse to consider?
Show answer and rationale
Correct answer: D. If the client has a suicide plan
The priority action to take with any client who is threatening suicide is to assess the client for a detailed suicide plan. After assessing whether the client is serious and has developed a plan, it would be appropriate to assess how long the client has felt this way and whether the client has a support system. As with any disorder, the chance of recovery is greater with treatment.
The nurse is signing a hospitalized client with bulimia back in after a day pass at home. Which of the following should be the nurse’s priority action?
Show answer and rationale
Correct answer: C. Search the client’s belonging for laxatives or diuretics
The priority action for the nurse to take when signing a client in from a pass at home is to search the client’s belongings for laxatives, diuretics, or ipecac that the client can hide and use while in the hospital. Asking what the client did on pass, what was eaten, or if there was any difficulty with binging and purging behavior is relevant, but not the priority.
The nurse is collecting a health history from a 25-year-old client suspected of having an eating disorder. Which of the following questions is a priority question for the nurse to ask the client?
Show answer and rationale
Correct answer: B. "Does your mother have an eating disorder?"
Although a father who works a lot and is away from home, a sibling with food issues, and a friend with a body image problem all may be important factors in the well-being of a client with an eating disorder, the priority is the mother-daughter connection. Theory exists questioning a possible mother-daughter connection as having the greatest impact on the client’s relationship with food.
The family of a male client suspected of having an eating disorder asks the nurse how their son can have an eating disorder because eating disorders only occur in women. Which of the following is the most appropriate response by the nurse?
Show answer and rationale
Correct answer: B. "The incidence of eating disorders is increasing in males."
Although eating disorders are generally the domain of females, the incidence in males is increasing.
Which of the following nursing diagnoses is appropriate for the nurse to include in the plan of care for a client with a binge disorder?
Show answer and rationale
Correct answer: D. Anxiety
An appropriate nursing diagnosis for a client with a binge disorder is anxiety. A client with a binge disorder feels a great deal of distress over the binge behavior. Ineffective thermoregulation and risk for health maintenance are nursing diagnoses appropriate for bulimia.
The nurse should administer which of the following drugs to a client with a binge-eating disorder for the purpose of decreasing the binge episodes?
Show answer and rationale
Correct answer: D. Sertraline (Zoloft)
Selective serotonin reuptake inhibitors, such as sertraline (Zoloft), are used to decrease the binge episodes in a client with a binge-eating disorder. Olanzapine (Zyprexa) is an antipsychotic that may be used to increase cooperation with treatment and promote weight gain in a client with anorexia nervosa. Amitriptyline (Elavil) and imipramine (Tofranil) are tricyclic antidepressants used in the treatment of depression.
A client with anorexia nervosa who is emaciated is crying and tells the nurse, "I feel so fat when I look in the mirror." Which of the following is the priority response for the nurse?
Show answer and rationale
Correct answer: B. "It must be very frightening to feel fat."
Telling the client with anorexia nervosa who is emaciated not to look in the mirror serves no purpose, because it is most likely an unrealistic goal. The client is obsessed with body image and frequently checks the mirror. Asking another person for his or her opinion also serves no purpose, because the client is obsessed with body size and most likely won’t trust another person’s opinion. The most effective intervention is for the nurse to be supportive of the client’s self-image and to encourage the client to verbalize a fear of being fat.
The nurse is caring for a client with bulimia who informs the nurse of an unpleasant tingling of the hands and around the mouth, as well as muscular spasms. The nurse should notify the physician of which of the following suspected disorders?
Show answer and rationale
Correct answer: A. Tetany
Tetany is a neuromuscular excitability associated with a critical decrease in the body’s calcium level. An unpleasant tingling of the hands and around the mouth and muscular spasms are characteristic of tetany. If emergency treatment is not begun, laryngospasms may develop.
The nurse is evaluating the medical records of the following four clients. It is essential that the nurse report which of the following clients immediately?
Show answer and rationale
Correct answer: C. A client with bulimia who has a serum calcium of 8.6 mg/dl
It is essential that the nurse report a client with bulimia who has a serum calcium level of 8.6 mg/dl. Normal serum calcium is 9.0 to 10.5 mg/dl. A client with a low calcium level is at risk for developing tetany, which can be a life-threatening condition. Although a client with anorexia nervosa who has a pulse of 55 beats per minute and a systolic blood pressure of 90�mm Hg has bradycardia and hypotension, reporting these is not as critical as impending tetany. A serum potassium of 3.5 mEq/L is within the normal range.
A 92-year-old client with emphysema is experiencing chest pain. The nurse determines with pulse oximetry that the oxygen saturation is 83%. The nurse understands that it is essential that oxygen be administered by nasal cannula at which of the following rates?
Show answer and rationale
Correct answer: D. 2 L/minute
In emphysema, the drive to breathe will be decreased or eliminated if oxygen is administered at a high rate. The best and safest initial rate of oxygen flow is 2 L to 3 L/minute. If higher flow rates are administered, the client may need artificial ventilation.
An 86-year-old client has sustained a fractured femur and has had surgery to repair the fracture. The client is rubbing the surgical site and moaning. Which of the following is the priority nursing intervention?
Show answer and rationale
Correct answer: D. Assess the client’s pain level
Older adults may rub or pat a painful area rather than verbalize the pain. The priority intervention is to assess the client’s pain level by asking the client. Administering pain medications, determining when the client had the last pain medication, and inspecting the surgical site are all appropriate interventions, but only after the current level of pain is assessed.
Which of the following is the appropriate assessment for respiratory depression in the older adult after the administration of an opioid for analgesia? Respiratory depression is
Show answer and rationale
Correct answer: A. most likely after the first dose.
Depending on the pain level, large doses may be prescribed for older adults. If a client is very sensitive to an opioid, the resulting respiratory depression is most likely to occur after the first dose. The route of administration will not decrease the likelihood of respiratory depression.
A 73-year-old client has just undergone a colostomy for cancer of the colon. The client tells the nurse the pain is "8" on a scale of 0 to 10. Which of the following is the expected outcome of the nursing care for this client?
Show answer and rationale
Correct answer: A. The client verbalizes satisfaction with the level of pain and pain control
An older adult in severe pain may not ask for pain medication because of a reluctance to "complain." The nurse cannot determine for the client what is an acceptable level of pain. A good outcome is achieved when the client can verbalize satisfaction with the level of pain and pain control.
The nurse assesses a 92-year-old client who has experienced a recent cerebral vascular accident (CVA) with a cranial nerve VII dysfunction to be exhibiting which of the following manifestations?
Show answer and rationale
Correct answer: A. Asymmetry of facial features
An asymmetry of facial features is specific to cranial nerve VII, the facial nerve. A difficulty in swallowing is associated with cranial nerve IX, the glossopharyngeal nerve. Loss of smell is common with injury to cranial nerve I, the olfactory nerve. Ptosis occurs with damage to cranial nerve III, the oculomotor nerve.
The nurse should include which of the following foods that has the most potassium per serving when instructing a 72-year-old client about foods that are high in potassium?
Show answer and rationale
Correct answer: A. Oranges
Citrus fruits, such as oranges, have the highest concentrations of potassium.
Which of the following is a priority for the nurse to assess when evaluating the hydration of an 87-year-old client?
Show answer and rationale
Correct answer: B. Blood pressure
Although weight and previous intake are important in evaluating hydration, blood pressure will give a more accurate indication of current hydration. Skin turgor should be checked in the older adult on the clavicle or forehead. A 24-hour intake of fluids may provide the nurse with additional information about the client’s hydration status, but it is not the priority.
During physical assessment of an older adult, the nurse should report which of the following cardiovascular changes that has occurred as a result of dehydration?
Show answer and rationale
Correct answer: C. Tachycardia
A narrowed pulse pressure and hypotension indicate dehydration and decreased circulating blood volume. Tachycardia and an increased respiratory rate indicate the body is attempting to increase the circulation of oxygen in the blood.
The nurse evaluates which of the following nursing assessment findings to be consistent with overhydration in a 72-year-old client admitted with congestive heart failure?
Show answer and rationale
Correct answer: B. Moist rales
Periorbital edema and edema of the hands are related to kidney failure and overhydration. Projectile vomiting in the older adult may be related to increased intracranial pressure. Moist rales indicate left-sided heart failure in a client with congestive heart failure.
A 93-year-old client has been functioning independently in the home but has suddenly become confused. A family member asks the nurse, "Does this mean Dad has Alzheimer’s disease?" Which of the following is the most appropriate response?
Show answer and rationale
Correct answer: A. "Confusion can be a sign of an infection in an older adult."
An older adult client who suddenly becomes�confused may have developed an infection, generally of the lungs and bladder,�or may be dehydrated. Confusion that�occurs in delirium, Alzheimer’s disease, and other forms of dementia develops slowly�and over time. Telling a client’s family�that the client may have dementia and�will have to be monitored over time shuts�down communication. Telling the family that the acute confusion may be a sign�of infection keeps communication open�and offers information. Rather than a "why" question, the nurse could ask for more recent history on the client, such as whether the client has experienced a fall or head injury.
A member of an older client’s family asks the nurse why medications are ordered at half of the usual dose. Which of the following is the most appropriate response?
Show answer and rationale
Correct answer: C. "Medications for the older adult may be at lower doses initially until responses are evaluated."
Older adults do not metabolize medications at the same rates as children and younger adults do. The liver and kidneys may have impaired function. Even though a thin older adult may have a body weight similar to that of a child, the dosage of medications must allow for age and comorbid conditions.
When the nurse is taking a nursing history on a client, the client mentions, "I slipped on a wet spot on the way to the bathroom." Which of the following is a priority for the nurse to ask?
Show answer and rationale
Correct answer: D. "Have you experienced any incontinent episodes?"
Although asking clients if they have started on any new medications, drink caffeinated beverages, or are excessively weak is relevant when taking a health history, the possibility of incontinence is significant because the client stated that the fall was the result of "slipping on a wet spot."
Which of the following should the nurse include in the medication instructions for an older adult who has back pain and for whom a mild opioid with codeine has been prescribed?
Show answer and rationale
Correct answer: D. Increase daily fiber and fluids
It is difficult for clients to count their own respirations accurately, and that measure is not necessary when taking codeine. The dosing of the medication should be "round the clock" to prevent severe pain. Older adult clients are more prone to constipation than younger clients, and fiber and fluids should be increased in the diet.
A hospice nurse caring for a terminally ill client should titrate the dose of morphine sulfate given to an older adult based on which of the following assessments?
Show answer and rationale
Correct answer: D. Level of pain
The level of pain acceptable to the client determines the dose of pain medication given to a hospice client. The pain medication is then titrated.
An older adult asks the nurse why a daily bath is necessary. The nurse should respond that daily bathing
Show answer and rationale
Correct answer: B. stimulates circulation, provides relaxation, and mobilizes joints.
Daily bathing may damage fragile skin in the older adult. Daily combing and brushing of the hair helps stimulate the scalp and distribute the oil. Reasons for daily bathing include stimulating circulation, providing relaxation, and mobilizing joints.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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