NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 131:

  A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on:

  A. Self-concept problems

  B. Interpersonal issues

  C. Ineffective coping skills

  D. Physiological stabilization

  Correct Answer: D

  (A) Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. (B) Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. (C) Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. (D) Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.

• Question 132:

  A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

  A. Orally in the morning and at bedtime

  B. Only one time during the day as long as it is always at the same time of day

  C. Rectally at bedtime

  D. As soon as she awakens, prior to any activity

  Correct Answer: D

  (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C) Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge.

• Question 133:

  The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?

  A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain."

  B. "Has anyone in your family ever had schizophrenia?"

  C. "If your son has a twin, he probably will eventually develop schizophrenia, too."

  D. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship."

  Correct Answer: A

  (A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother.

• Question 134:

  A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?

  A. Sitting with legs crossed at ankles

  B. Wearing thromboembolic disease (TED) stockings

  C. Wearing support pantyhose

  D. Wearing knee-high stockings

  Correct Answer: D

  (A) Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points. (B) TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. (C) Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. (D) Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.

• Question 135:

  A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

  A. High fever, tachycardia, stupor, renal failure

  B. Lip smacking, chewing, blinking, lateral jaw movements

  C. Photosensitivity, orthostatic hypotension, dry mouth

  D. Constipation, blurred vision, drowsiness

  Correct Answer: B

  (A) These symptoms are found in clients with neuroleptic malignant syndrome. (B) These symptoms are found in clients with tardive dyskinesia. (C) These are normal side effects found in clients taking antipsychotic medications. (D) These are also normal side effects found in clients taking antipsychotic medications.

• Question 136:

  A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is:

  A. Initial maternal-infant bonding may be poor.

  B. Client may have a poor relationship with her husband.

  C. This response is normal in the first trimester.

  D. This response is abnormal, to be re-evaluated at the next visit.

  Correct Answer: C

  (A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of "not now" in the first trimester. The statement still leaves room for exploration. (B) There are no data to support this. This statement by the mother still leaves room for exploration. (C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of "not now." This fact should be shared with the mother during further exploration of the comment. (D) It is not abnormal. If it were, another month would also be too long to wait.

• Question 137:

  A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, "Isn't that a lot?" The nurse's best response is:

  A. "Yes, that does seem like a lot."

  B. "You'll have to talk to the doctor about that. The physician knows what's best for the client."

  C. "Six to 10 treatments are common. Are you concerned about permanent effects?"

  D. "Don't worry. Some clients have lots more than that."

  Correct Answer: C

  (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband's question is well within the nurse's knowledge base. (C) The most common range for affective disorders is 6?0 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife.

• Question 138:

  A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?

  A. Antipsychotic medications

  B. Antidepressant medications

  C. Antianxiety medications

  D. Antimania medication

  Correct Answer: C

  (A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).

• Question 139:

  On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

  A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes

  B. Allow the infant to breast-feed at the next feeding time to empty the breasts

  C. Apply ice packs to the breasts and wear a supportive, well-fitting bra

  D. Take a warm shower and express milk from both breasts until empty

  Correct Answer: C

  (A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112? hours will reduce and/or prevent breast engorgement. Breastfeeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.

• Question 140:

  The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:

  A. Dorsiflexes her ankle

  B. Flexes her spine

  C. Plantiflexes her wrist

  D. Turns her head to the side

  Correct Answer: B

  (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.