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NCLEX-RN Exam Questions - Part 71
1. A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
A) Activity intolerance
B) Ineffective airway clearance
C) High risk for infection
D) Altered oral mucous membrane
2. A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
A) Providing opportunities to ask questions and talk about concerns
B) Providing distractors such as reading or watching television
C) Telling her that she should not be so nervous and assuring her that everything will be OK
D) Reminding her that this surgery is not as extensive as her past surgery was
3. On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
A) 'You will not be allowed to remain in your room if you continue to bother things.'
B) 'I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit.'
C) 'Tell me why your room needs to be so clean.'
D) 'I - ve inspected this room and it is perfectly clean.'
4. The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?
A) Prolonged use of this medication will result in extrapyramidal side effects.
B) When the medication is effective, he will experience no anxiety.
C) The medication should relieve his symptoms of depression.
D) Blood must be drawn weekly to test for toxicity.
5. The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
A) Reduce his anxiety
B) Avoid going to psychotherapy
C) Manipulate the health team members
D) Increase his self-image by showing higher standards than the fellow clients
A) Activity intolerance
B) Ineffective airway clearance
C) High risk for infection
D) Altered oral mucous membrane
2. A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
A) Providing opportunities to ask questions and talk about concerns
B) Providing distractors such as reading or watching television
C) Telling her that she should not be so nervous and assuring her that everything will be OK
D) Reminding her that this surgery is not as extensive as her past surgery was
3. On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
A) 'You will not be allowed to remain in your room if you continue to bother things.'
B) 'I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit.'
C) 'Tell me why your room needs to be so clean.'
D) 'I - ve inspected this room and it is perfectly clean.'
4. The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?
A) Prolonged use of this medication will result in extrapyramidal side effects.
B) When the medication is effective, he will experience no anxiety.
C) The medication should relieve his symptoms of depression.
D) Blood must be drawn weekly to test for toxicity.
5. The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
A) Reduce his anxiety
B) Avoid going to psychotherapy
C) Manipulate the health team members
D) Increase his self-image by showing higher standards than the fellow clients
1. Right Answer: B
Explanation: (A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 2448 hours. The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The clients mouth may become dry, but good oral care should take care of the dryness.
2. Right Answer: A
Explanation: (A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B)Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the clients anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the clients past experiences.
3. Right Answer: B
Explanation: (A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some positive activity is therapeutic. (C) The client cannot say 'why'; this statement puts the client on the defensive. (D) A rational approach, especially a judgmental one, is nontherapeutic.
4. Right Answer: C
Explanation: (A) Phenothiazines cause extrapyramidal symptoms. (B) No amount of medication can relieve all anxiety in all cases. (C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an antidepressant. It increases the action of norepinephrine and serotonin on nerve cells. (D) Periodic blood tests are done when lithium is prescribed.
5. Right Answer: A
Explanation: (A) These behaviors are attempts to relieve anxiety. (B) Avoidance is not a pattern in the obsessive client. (C) Although these behaviors may seem to manipulate others, that is not the purpose behind the activity. (D) Inflated self-esteem is not a characteristic of the severely anxious client.
Explanation: (A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 2448 hours. The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The clients mouth may become dry, but good oral care should take care of the dryness.
2. Right Answer: A
Explanation: (A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B)Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the clients anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the clients past experiences.
3. Right Answer: B
Explanation: (A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some positive activity is therapeutic. (C) The client cannot say 'why'; this statement puts the client on the defensive. (D) A rational approach, especially a judgmental one, is nontherapeutic.
4. Right Answer: C
Explanation: (A) Phenothiazines cause extrapyramidal symptoms. (B) No amount of medication can relieve all anxiety in all cases. (C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an antidepressant. It increases the action of norepinephrine and serotonin on nerve cells. (D) Periodic blood tests are done when lithium is prescribed.
5. Right Answer: A
Explanation: (A) These behaviors are attempts to relieve anxiety. (B) Avoidance is not a pattern in the obsessive client. (C) Although these behaviors may seem to manipulate others, that is not the purpose behind the activity. (D) Inflated self-esteem is not a characteristic of the severely anxious client.
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