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NCLEX-RN Exam Questions - Part 73
1. A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being 'bugged.' Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
A) Protect her from suicide
B) Enable her to develop trust
C) Supervise her medication regimen
D) Involve her in groups for social interaction
2. The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
A) Hypotension
B) Photosensitivity
C) Excessive appetite
D) Dryness of the mouth
3. Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:
A) Assigning her to occupational therapy
B) Having her sit with the nurses while they chart
C) Helping her to make friends
D) Facilitating communication
4. A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
A) Flight of ideas
B) Delusions
C) Hallucinations
D) Echolalia
5. A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
A) 1.0 mEq/L
B) 2.2 mEq/L
C) 0.03 mEq/L
D) 1.5 mEq/L
A) Protect her from suicide
B) Enable her to develop trust
C) Supervise her medication regimen
D) Involve her in groups for social interaction
2. The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
A) Hypotension
B) Photosensitivity
C) Excessive appetite
D) Dryness of the mouth
3. Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:
A) Assigning her to occupational therapy
B) Having her sit with the nurses while they chart
C) Helping her to make friends
D) Facilitating communication
4. A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
A) Flight of ideas
B) Delusions
C) Hallucinations
D) Echolalia
5. A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
A) 1.0 mEq/L
B) 2.2 mEq/L
C) 0.03 mEq/L
D) 1.5 mEq/L
1. Right Answer: B
Explanation: (A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement.(C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.
2. Right Answer: B
Explanation: (A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a factor influenced by a picnic in the park. (B) Protection from the sun is important in clients taking phenothiazines because they burn easily and severely. (C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a picnic. (D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.
3. Right Answer: D
Explanation: (A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.
4. Right Answer: A
Explanation: (A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ('hearing voices'). (D) Repeating words is called echolalia.
5. Right Answer: D
Explanation: (A) This value is a low blood level. (B) This value is a toxic blood level. (C) This value is a low blood level. (D) This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
Explanation: (A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement.(C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.
2. Right Answer: B
Explanation: (A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a factor influenced by a picnic in the park. (B) Protection from the sun is important in clients taking phenothiazines because they burn easily and severely. (C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a picnic. (D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.
3. Right Answer: D
Explanation: (A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.
4. Right Answer: A
Explanation: (A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ('hearing voices'). (D) Repeating words is called echolalia.
5. Right Answer: D
Explanation: (A) This value is a low blood level. (B) This value is a toxic blood level. (C) This value is a low blood level. (D) This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
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