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NCLEX-RN Exam Questions - Part 113
1. 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
2. A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A) 'I did not get the raise because my boss does not like me.'
B) 'I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister - s wedding.'
C) 'My son died 3 years ago. I still cannot bring myself to clean out his room.'
D) 'My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company - s board meeting today.'
3. When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
A) Be direct, honest, and attentive.
B) Approach them in the emergency room as soon as you suspect abuse to 'clear the air' right away.
C) Ask the parents what they could have done differently to prevent this from happening to the child.
D) After the interview, call child protective services.
4. In an interview for suspected child abuse, the childs mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child - s father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
A) Fear related to retaliation by the father
B) Actual injury related to poor impulse control by the father
C) Ineffective coping
D) Altered family process related to physical abuse
5. As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
A) Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
B) Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
C) Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
D) Do not leave the victim alone to collect her thoughts.
A) Dyskinesia
B) Akathisia
C) Echopraxia
D) Echolalia
2. A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A) 'I did not get the raise because my boss does not like me.'
B) 'I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister - s wedding.'
C) 'My son died 3 years ago. I still cannot bring myself to clean out his room.'
D) 'My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company - s board meeting today.'
3. When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
A) Be direct, honest, and attentive.
B) Approach them in the emergency room as soon as you suspect abuse to 'clear the air' right away.
C) Ask the parents what they could have done differently to prevent this from happening to the child.
D) After the interview, call child protective services.
4. In an interview for suspected child abuse, the childs mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child - s father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
A) Fear related to retaliation by the father
B) Actual injury related to poor impulse control by the father
C) Ineffective coping
D) Altered family process related to physical abuse
5. As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
A) Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
B) Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
C) Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
D) Do not leave the victim alone to collect her thoughts.
1. Right Answer: A
Explanation: (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.
2. Right Answer: D
Explanation: (A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The clients actions are an example of maladaptive denial. She is denying her sons death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husbands statement but delays discussion until she can devote her full attention to the matter.
3. Right Answer: A
Explanation: (A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parents trust. (B) The nurse should approach the parents in private, away from the child. (C) Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child s 'accident.' At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.
4. Right Answer: D
Explanation: (A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the childs injuries.(C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
5. Right Answer: A
Explanation: (A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D)Once the victim enters the emergency room, it is important not to leave her alone.
Explanation: (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.
2. Right Answer: D
Explanation: (A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The clients actions are an example of maladaptive denial. She is denying her sons death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husbands statement but delays discussion until she can devote her full attention to the matter.
3. Right Answer: A
Explanation: (A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parents trust. (B) The nurse should approach the parents in private, away from the child. (C) Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child s 'accident.' At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.
4. Right Answer: D
Explanation: (A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the childs injuries.(C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
5. Right Answer: A
Explanation: (A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D)Once the victim enters the emergency room, it is important not to leave her alone.
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