NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 111:

  A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:

  A. Akathisia

  B. Akinesia

  C. Dystonia

  D. Opisthotonos

  Correct Answer: A

  (A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.

• Question 112:

  A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, "Nobody in here seems to really care about the clients. I thought nurses cared about people!" The client is exhibiting the ego defense mechanism:

  A. Reaction formation

  B. Rationalization

  C. Splitting

  D. Sublimation

  Correct Answer: C

  (A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.

• Question 113:

  A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:

  A. Provide cathartic action within the colon

  B. Reduce the risk of wound infection from anaerobic bacteria

  C. Relieve the client's concern regarding possible infection

  D. Reduce the risk of intraoperative fever

  Correct Answer: B

  (A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.

• Question 114:

  A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:

  A. Establishing routine tasks and activities around mealtimes

  B. Administering medications such as lithium

  C. Requiring the client to eat more during meals

  D. Checking the client's room frequently

  Correct Answer: A

  (A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client's feelings of powerlessness. (D) Like the previous strategy, checking the client's room frequently contributes to the client's feelings of powerlessness.

• Question 115:

  A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:

  A. "You should ask your doctor about this."

  B. "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin."

  C. "No, do not increase your insulin. Exercise will not affect your insulin needs."

  D. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells."

  Correct Answer: D

  (A) A nurse can give this information to a client. (B) Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. (C) Exercise makes insulin more efficient unless the diabetes is poorly controlled. (D) Exercise makes insulin more efficient in moving more glucose into the cells.

• Question 116:

  A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of: A. Scoliosis

  B. Dislocated hip

  C. Fractured femur

  D. Fractured pelvis

  Correct Answer: B

  (A, C, D) A Trendelenburg gait is not characteristic of any of these disorders. (B) The downward slant of one hip is a positive sign of dislocation in the weight-bearing hip. If one hip is dislocated, the child walks with a characteristic limp known as the Trendelenburg gait.

• Question 117:

  Which stage of labor lasts from delivery of the baby to delivery of the placenta?

  A. Second

  B. Third

  C. Fourth

  D. Fifth

  Correct Answer: B

  (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor.

• Question 118:

  A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

  A. Dims the lights in her room

  B. Encourages her to breathe slowly and deeply

  C. Offers sips of warm liquids

  D. Places a large, soft pillow under her head

  Correct Answer: A

  (A) The discomfort of photophobia is alleviated by dimming the lights. (B) Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. (C) It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. (D) A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.

• Question 119:

  Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:

  A. Subsides in<3 weeks

  B. Is relieved by aspirin

  C. Is responsive to ibuprofen (Motrin)

  D. Subsides in 3

  Correct Answer: A

  (A) Joints usually remain inflamed and tender until the disease runs its course in<3 weeks. (B) This response does not answer the question of whether she will always be arthritic. (C) This response does not answer the question asked. (D) The disease takes<3 weeks to run its course.

• Question 120:

  A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:

  A. Tell the physician her concerns

  B. Report her suspicions to the authorities

  C. Talk to the child's father

  D. Confront the child's mother

  Correct Answer: B

  (A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.