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NCLEX-RN Exam Questions - Part 136
1. A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he - s going to cut out my heart.' The nurse - s best response is:
A) 'I know you - re feeling frightened right now, but I want you to know that I don - t see anyone in the corner.'
B) 'You - ll probably see strange things for a while until the PCP wears off.'
C) 'Try to sleep. When you wake up, the devil will be gone.'
D) 'You - re probably feeling guilty because you used illegal drugs tonight.'
2. A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A) Give fluids if the client requests them.
B) Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C) Measure vital signs at least every 4 hours.
D) Release restraints every 2 hours for client to exercise.
3. After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
A) Lorazepam (Ativan)
B) Benztropine (Cogentin)
C) Thiothixene (Navane)
D) Flurazepan (Dalmane)
4. Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
A) The physician orders it
B) A therapeutic alliance has been established, and violent behavior subsides
C) The violent behavior subsides, and the client agrees to behave
D) The nurse deems that removal of restraints is necessary
5. A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is5 - 4' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
A) Obtain an accurate weight
B) Search the client - s purse for pills
C) Assess vital signs
D) Assign her to a room with someone her own age
A) 'I know you - re feeling frightened right now, but I want you to know that I don - t see anyone in the corner.'
B) 'You - ll probably see strange things for a while until the PCP wears off.'
C) 'Try to sleep. When you wake up, the devil will be gone.'
D) 'You - re probably feeling guilty because you used illegal drugs tonight.'
2. A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A) Give fluids if the client requests them.
B) Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C) Measure vital signs at least every 4 hours.
D) Release restraints every 2 hours for client to exercise.
3. After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
A) Lorazepam (Ativan)
B) Benztropine (Cogentin)
C) Thiothixene (Navane)
D) Flurazepan (Dalmane)
4. Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
A) The physician orders it
B) A therapeutic alliance has been established, and violent behavior subsides
C) The violent behavior subsides, and the client agrees to behave
D) The nurse deems that removal of restraints is necessary
5. A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is5 - 4' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
A) Obtain an accurate weight
B) Search the client - s purse for pills
C) Assess vital signs
D) Assign her to a room with someone her own age
1. Right Answer: A
Explanation: (A) The nurse is the clients link to reality. This response validates the authenticity of the clients experience by casting doubt on his belief and reinforcing reality.(B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the clients feelings by offering a nontherapeutic interpretation of the motivation for the clients actions.
2. Right Answer: D
Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 12 hours. (D)Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
3. Right Answer: B
Explanation: (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B)Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.
4. Right Answer: B
Explanation: (A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only 'agrees to behave' after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
5. Right Answer: C
Explanation: (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
Explanation: (A) The nurse is the clients link to reality. This response validates the authenticity of the clients experience by casting doubt on his belief and reinforcing reality.(B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the clients feelings by offering a nontherapeutic interpretation of the motivation for the clients actions.
2. Right Answer: D
Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 12 hours. (D)Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
3. Right Answer: B
Explanation: (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B)Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.
4. Right Answer: B
Explanation: (A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only 'agrees to behave' after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
5. Right Answer: C
Explanation: (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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