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NCLEX-RN Exam Questions - Part 114
1. A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
A) Dissociation
B) Intellectualization
C) Rationalization
D) Displacement
2. A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?
A) Ask him to sit down. Speak slowly and use short, simple sentences.
B) Help him to recognize his anxiety.
C) Walk with him as he paces.
D) Increase the level of his supervision.
3. A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
A) He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
B) He enters a concert, but as the lights dim, he does not experience anxiety.
C) He states that he no longer fears dark places.
D) He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
4. A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?
A) Maintain a normal diet; however, limit salt intake to no more than 3 g/day.
B) Take lithium between meals to increase absorption.
C) Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.
D) For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti-inflammatory drugs are preferred.
5. For the past several months, an elderly female client with Alzheimers disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
A) Tardive dyskinesia, which may be a side effect of antipsychotic medication
B) Early symptoms of Parkinson - s disease
C) A more advanced stage of Alzheimer - s disease than previously experienced by the client
D) The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
A) Dissociation
B) Intellectualization
C) Rationalization
D) Displacement
2. A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?
A) Ask him to sit down. Speak slowly and use short, simple sentences.
B) Help him to recognize his anxiety.
C) Walk with him as he paces.
D) Increase the level of his supervision.
3. A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
A) He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
B) He enters a concert, but as the lights dim, he does not experience anxiety.
C) He states that he no longer fears dark places.
D) He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
4. A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?
A) Maintain a normal diet; however, limit salt intake to no more than 3 g/day.
B) Take lithium between meals to increase absorption.
C) Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.
D) For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti-inflammatory drugs are preferred.
5. For the past several months, an elderly female client with Alzheimers disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
A) Tardive dyskinesia, which may be a side effect of antipsychotic medication
B) Early symptoms of Parkinson - s disease
C) A more advanced stage of Alzheimer - s disease than previously experienced by the client
D) The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
1. Right Answer: B
Explanation: (A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B)Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. (C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D)Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
2. Right Answer: C
Explanation: (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control.
3. Right Answer: A
Explanation: (A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
4. Right Answer: C
Explanation: (A) The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. (B) Lithium must be taken with meals because it is irritating to the gastric mucosa. (C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. (D) Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.
5. Right Answer: A
Explanation: (A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. (B)Although mild tremors are an early sign of Parkinsons disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimers disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
Explanation: (A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B)Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. (C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D)Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
2. Right Answer: C
Explanation: (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control.
3. Right Answer: A
Explanation: (A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
4. Right Answer: C
Explanation: (A) The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. (B) Lithium must be taken with meals because it is irritating to the gastric mucosa. (C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. (D) Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.
5. Right Answer: A
Explanation: (A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. (B)Although mild tremors are an early sign of Parkinsons disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimers disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
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