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NCLEX-RN Exam Questions - Part 128
1. A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
A) Always allow the most vocal person to state the problem first.
B) Encourage the mother to speak for the children.
C) Interpret immediately what seems to be going on within the family.
D) Allow family members to assume the seats as they choose.
2. In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
A) Crisis intervention with an intoxicated teenager whose mother just committed suicide
B) Referring a client who has been on a detoxification unit to a rehabilitation center
C) Teaching fifth-grade children the harmful effects of substance abuse
D) Counseling a client with post-traumatic stress disorder
3. While the nurse is taking a male client - s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A) Politely tells the client, 'Keep your hands off '
B) Ignores the remarks and hopes he will not try it again
C) Confronts the remarks but attempts not to reject the client
D) Leaves the room in order to compose herself
4. A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
A) Promises of gifts that her husband made to her
B) Acute battering of the client, characterized by his volatile discharge of tension
C) Minor battering incidents, such as the throwing of food or dishes at her
D) A period of tenderness between the couple
5. Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A) Fine hand tremor, headache, mental dullness
B) Vomiting, impaired consciousness, decreased blood pressure
C) Polyuria, polydipsia, edema
D) Gastric irritation, nausea, diarrhea
A) Always allow the most vocal person to state the problem first.
B) Encourage the mother to speak for the children.
C) Interpret immediately what seems to be going on within the family.
D) Allow family members to assume the seats as they choose.
2. In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
A) Crisis intervention with an intoxicated teenager whose mother just committed suicide
B) Referring a client who has been on a detoxification unit to a rehabilitation center
C) Teaching fifth-grade children the harmful effects of substance abuse
D) Counseling a client with post-traumatic stress disorder
3. While the nurse is taking a male client - s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A) Politely tells the client, 'Keep your hands off '
B) Ignores the remarks and hopes he will not try it again
C) Confronts the remarks but attempts not to reject the client
D) Leaves the room in order to compose herself
4. A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
A) Promises of gifts that her husband made to her
B) Acute battering of the client, characterized by his volatile discharge of tension
C) Minor battering incidents, such as the throwing of food or dishes at her
D) A period of tenderness between the couple
5. Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A) Fine hand tremor, headache, mental dullness
B) Vomiting, impaired consciousness, decreased blood pressure
C) Polyuria, polydipsia, edema
D) Gastric irritation, nausea, diarrhea
1. Right Answer: D
Explanation: (A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions.(B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D)Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
2. Right Answer: C
Explanation: (A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
3. Right Answer: C
Explanation: (A) This response does not recognize normal feelings of attraction and rejects the client. (B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.
4. Right Answer: C
Explanation: (A) This description is characteristic of the 'honeymoon' or 'respite' phase. (B) This description is characteristic of the 'battering' phase. (C) This description is characteristic of the 'tension- building' phase prior to the volatile discharge of tension found in the battering phase. (D) This description is characteristic of the'honeymoon' or 'respite' phase.
5. Right Answer: B
Explanation: (A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium. (B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
Explanation: (A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions.(B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D)Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
2. Right Answer: C
Explanation: (A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
3. Right Answer: C
Explanation: (A) This response does not recognize normal feelings of attraction and rejects the client. (B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.
4. Right Answer: C
Explanation: (A) This description is characteristic of the 'honeymoon' or 'respite' phase. (B) This description is characteristic of the 'battering' phase. (C) This description is characteristic of the 'tension- building' phase prior to the volatile discharge of tension found in the battering phase. (D) This description is characteristic of the'honeymoon' or 'respite' phase.
5. Right Answer: B
Explanation: (A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium. (B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
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