NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 251:

  A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?

  A. A daily dose of fluoxetine may be taken in the morning or evening.

  B. Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities are not necessary.

  C. Rashes or pruritus usually occur early in the therapy and are treatable without discontinuing the medication.

  D. It is safe to take over-the-counter or other prescription medications with fluoxetine.

  Correct Answer: C

  (A) A daily dose of fluoxetine should be taken in the morning. Afternoon doses may cause nervousness and insomnia. (B) Although fluoxetine is less sedating than other antidepressants, it may still cause dizziness or drowsiness in some clients. The nurse should caution clients to avoid driving or hazardous activities until the central nervous system effects of the drug are demonstrated. (C) Rashes or pruritus do commonly occur early in therapy and respond to antihistamines or topical corticosteroids. (D) Advise the client not to take over-the-counter or other prescription drugs without consulting with the physician. Fluoxetine does interact with other common drugs such as monoamine oxidase inhibitors, diazepam, insulin, oral antidiabetic agents, tricyclic antidepressants, and tryptophan.

• Question 252:

  A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, "I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like." This defense mechanism is an example of:

  A. Repression

  B. Regression

  C. Reaction formation

  D. Rationalization

  Correct Answer: D

  (A) Repression is blocking a desire from conscious expression. The client is conscious of his desires. (B) Regression is returning to an earlier form of expression, which is not demonstrated here. (C) Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. (D) Rationalization is unconsciously falsifying an experience by giving a "rational" explanation. The client is attempting to justify his behavior by giving an explanation.

• Question 253:

  A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:

  A. Rubra

  B. Rosa

  C. Serosa

  D. Alba

  Correct Answer: C

  (A) Lochia rubra is bloody with clots and occurs 1? days postpartum. (B) There is no such term as lochia rosa. (C) Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4? days postpartum. (D) Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.

• Question 254:

  Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

  A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.

  B. She places her infant on her right side after feeding her.

  C. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.

  D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.

  Correct Answer: C

  (A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.

• Question 255:

  To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:

  A. Dangle the client's legs over the edge of the bed every shift.

  B. Massage the client's calves briskly every shift.

  C. Keep the client's legs extended and discourage any movement.

  D. Have the client tighten and relax leg muscles several times daily.

  Correct Answer: D

  (A) Dangling the client's legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the client's calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D) Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.

• Question 256:

  A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?

  A. Identity versus role confusion

  B. Integrity versus despair

  C. Intimacy versus isolation

  D. Generativity versus self-absorption

  Correct Answer: D

  (A) Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. (B) Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. (C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. (D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.

• Question 257:

  A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing "strange things." The nurse reassures the wife that the following behavior is normal with Parkinson's disease:

  A. "Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods."

  B. "Your husband may move his hands in motions that look like he is rolling a pill between his fingers."

  C. "Twitching of the muscles is to be expected and can occur at any time during the day."

  D. "Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times."

  Correct Answer: B

  (A) Clients with Parkinson's disease generally experience stiffness and rigid movement. (B) Pill-rolling movements are a symptom experienced by the Parkinson client. (C) Twitching of the muscles is not an expected symptom of Parkinson's disease. (D) Parkinson's disease does not cause joint pain. Mild muscular pain may be present.

• Question 258:

  During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

  A. Dyskinesia

  B. Akathisia

  C. Echopraxia

  D. Echolalia

  Correct Answer: A

  (A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. (B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. (C) Echopraxia is mimicking the movements of another person. (D) Echolalia is mimicking the speech of another person.

• Question 259:

  At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

  A. Apical pulse of 52 bpm

  B. Uterine fundus palpable left of midline

  C. No bowel movement since delivery

  D. Oral temperature of 100.4F

  Correct Answer: B

  (A) Bradycardia of 50?0 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. (C) Re- establishment of normal bowel function is delayed into the first postpartum week. (D) A postpartum woman's oral temperature may go as high as 100.4_F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.

• Question 260:

  A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

  A. Evaluation of his level of consciousness

  B. Evaluation of an electrocardiogram

  C. Measurement of his urine output for the past 8 hours

  D. Serum potassium lab values for the last several days

  Correct Answer: B

  (A)

  The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level.

  (C)

  Measurement of the urine output is not a priority nursing action at this time. (D) The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.