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NCLEX-RN Exam Questions - Part 92
1. The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
A) Maintaining an adequate level of hydration
B) Providing pain relief
C) Preventing infection
D) O2 therapy
2. A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
A) Encourages the client to discuss the voices
B) Attempts to direct the client - s attention to the here and now
C) Exhibits sincere interest in the delusional voices
D) Gives the medication as necessary for the acting-out behavior
3. One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The clients level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
A) Within therapeutic range
B) Below therapeutic range
C) Above therapeutic range
D) At a level of toxic poisoning
4. A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
A) Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
B) Restrict fluids to 1000 mL/day.
C) Restrict foods that contain salt or sodium.
D) Discontinue the medication if nausea occurs.
5. A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:
A) Role playing the client - s eating behaviors
B) Restriction to the unit until she has gained 2 lb
C) Encouraging her to verbalize her feelings concerning food and food intake
D) Provision for a high-calorie, high-protein snack between meals
A) Maintaining an adequate level of hydration
B) Providing pain relief
C) Preventing infection
D) O2 therapy
2. A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
A) Encourages the client to discuss the voices
B) Attempts to direct the client - s attention to the here and now
C) Exhibits sincere interest in the delusional voices
D) Gives the medication as necessary for the acting-out behavior
3. One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The clients level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
A) Within therapeutic range
B) Below therapeutic range
C) Above therapeutic range
D) At a level of toxic poisoning
4. A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
A) Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
B) Restrict fluids to 1000 mL/day.
C) Restrict foods that contain salt or sodium.
D) Discontinue the medication if nausea occurs.
5. A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:
A) Role playing the client - s eating behaviors
B) Restriction to the unit until she has gained 2 lb
C) Encouraging her to verbalize her feelings concerning food and food intake
D) Provision for a high-calorie, high-protein snack between meals
1. Right Answer: A
Explanation: (A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
2. Right Answer: B
Explanation: (A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
3. Right Answer: A
Explanation: (A) This answer is correct. The therapeutic range is 1.01.5 mEq/L in the acute phase. Maintenance control levels are 0.61.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.
4. Right Answer: A
Explanation: (A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (20003000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
5. Right Answer: B
Explanation: (A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
Explanation: (A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
2. Right Answer: B
Explanation: (A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
3. Right Answer: A
Explanation: (A) This answer is correct. The therapeutic range is 1.01.5 mEq/L in the acute phase. Maintenance control levels are 0.61.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.
4. Right Answer: A
Explanation: (A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (20003000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
5. Right Answer: B
Explanation: (A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
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