nclex questions Flashcards
An individual who recently celebrated his 65th birthday is planning to retire from the job he has held for the last 35 years. His place of employment is providing information on how to adjust to the change in lifestyle. The industrial nurse leading the workshop is aware that if the individual does experience an adjustment disorder, it will likely be related to:
A. loss of identity and purpose.
B. concern about finances.
C. boredom from having few interests.
D. loneliness from having to spend time alone.
A. loss of identity and purpose.
Rationale: Identity and purpose are often associated with one’s job. When one retires, loss of identity and purpose often occur, which requires adaptation. If adaptation does not occur, adjustment disorder may result. Options 2, 3, and 4 are not the most frequent causes of postretirement adjustment disorder.
A patient who has adjustment disorder with depressed mood has been given the nursing diagnosis of risk for self-directed violence. Which patient outcome would best address this diagnosis? Patient will:
A. notify nurse if he feels more depressed.
B. verbalize no suicidal ideations while hospitalized.
C. keep a journal describing any self-destructive thoughts.
D. not harm self while in the hospital.
D. not harm self while in the hospital.
Rationale: This “no harm” outcome is the most definitive and the most desirable of all those listed.
Which of the following questions asked by the nurse would be effective in gaining data about a patient’s coping skills?
A. “Can you tell me about your family and available support system?”
B. “What has happened in your life recently?”
C. “How do you think others your age would handle this?”
D. “How have you handled events like this in the past?”
D. “How have you handled events like this in the past?”
Rationale: This question asks directly about the coping skills used in the past. After this lead-in the nurse can question
further to find out how effective the coping skills were. This option is the only question that relates specifically to adequacy of coping skills.
Which of these actions taken by inexperienced health care professionals would block grief resolution when a patient experiences a loss?
A. Attempting to obtain detailed information about the loss
B. Feeling empathy for the patient
C. Failing to recognize cultural custom
D. Seeking assistance from the pastoral care department
C. Failing to recognize cultural custom
Rationale: Cultural practices dealing with grief and loss differ. Failure to incorporate
the significance of cultural practices into the treatment plan may impede
resolution of the patient’s grieving. 1. Talking about the loss helps the
patient come to terms with it. 2. Empathy is a helpful response. 4. Obtaining
help from qualified persons to assist with grief resolution is valuable if the
patient approves of their involvement.
Which of these observations suggests an improvement in a patient who was diagnosed with adjustment disorder with depressed mood?
A. Asking to participate with a group preparing a meal on the unit
B. Walking to the medicine room to get prn medications
C. Visiting with the minister during visiting hours
D. Attending group therapy
A. Asking to participate with a group preparing a meal on the unit
Rationale: The desire to actively participate with others in meal preparation demonstrates that the patient is less depressed. Most depressed patients prefer solitude. 2. Use of prn medication suggests continuation of symptoms. 3. This is not an indicator of improvement. 4. Group therapy is part of the treatment program, not an optional activity.
A patient, age 54, is preparing for discharge from outpatient therapy, having
been diagnosed and treated for adjustment disorder with anxious mood. Which
statement indicates that the patient has developed an adequate strategy for
coping with the problem of disturbed sleep pattern?
A. “I know I must take a sleeping medication in order to sleep.”
B. “Listening to relaxation tapes helps me get to sleep.”
C. “I sleep better after I drink a small glass of wine.”
D. “When I can’t sleep, I will call my friend, who is always willing to listen to me.”
B. “Listening to relaxation tapes helps me get to sleep.”
Rationale: Listening to relaxation tapes indicates the patient has learned an effective method to cope with the
problem of disturbed sleep. 1. Continued use of hypnotics is to be discouraged. 3. Use of alcohol will not improve sleep disturbance. 4. This method of dealing with sleep disturbance may cost the patient a friend.
Appropriate discharge criteria for a patient with chronic anxiety disorder are that the patient will:
A. Recognize the need to take medications for life to control anxiety
B. Experience no more anxiety
C. Identify situations and events that trigger anxiety
D. Suppress anxiety symptoms and focus on the future
C. Identify situations and events that trigger anxiety
Which nursing diagnosis would be most useful for patients with anxiety
disorders when the following defining characteristics have been identified:
avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle
response, detachment, numbing, and flashbacks?
A. Anxiety
B. Powerlessness
C. Disturbed sensory perception
D. Post-trauma syndrome
D. Post-trauma syndrome
Rationale: Circumscribed anxiety disorders including post-trauma syndrome and rape-trauma syndrome are related to specific antecedent traumatic events. The defining characteristics given are those of post-trauma syndrome. Pervasive disorders have no clearly identifiable antecedent even and have defining characteristics that include many physiological sympathetic and parasympathetic symptoms along with behavioral, affective, and cognitive symptoms. Options 1, 2, and 3 each address only a single aspect and are therefore of limited usefulness when compared with option 4.
The nurse must plan health teaching for a patient with generalized anxiety disorder who is taking lorazepam (Ativan). Which topic should be included? A. Tyramine-free diet B. Caffeine restriction C. Skin care to prevent breakdown D. Dietary restriction of tryptophan
B. Caffeine restriction
Rationale: Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee.
The patient tells the nurse he feels as though something terrible is going to happen to him and displays symptoms of increased vital signs, dilated pupils, urinary frequency, rigid muscles, and decreased hearing. The nurse would assess these findings as being indicative of anxiety at the level of: A. Mild B. Moderate C. Severe D. Panic
C. Severe
Rationale: In severe anxiety autonomic symptoms are pronounced, and sensory perceptions are decreased because the individual has entered the fight-or-flight stage of response.
Which statement made by a patient who washes his or her hands compulsively identifies the thinking typical of a patient with obsessive-compulsive disorder?
A. “I know I’ll get my hands clean eventually; it just takes time.”
B. “I need a milder soap that won’t damage my hands so much.”
C. “I feel so much better when my hands are clean. I can get on to do other things.”
D. “I feel driven to wash my hands, although I don’t like doing it.”
D. “I feel driven to wash my hands, although I don’t like doing it.”
Rationale: The individual who uses obsessive-compulsive rituals generally acknowledges that the ritualistic behavior is not constructive and that he or she does not like doing it.
A patient was admitted with a diagnosis of agoraphobia with panic attacks. Which of the following symptoms would the nurse expect the patient to experience during a panic attack? A. Paresthesias B. Constipation C. Feigned fears D. Hypotension
A. Paresthesias
Rationale: According to the DSM-IV-TR criteria, paresthesias are often present during a panic attack. 2. Diarrhea, rather than constipation is seen. 3. During a panic attack the patient is not feigning fear; the sensations are very real. 4. Hypertension would be expected.
A patient has a history of pain related to at least four different sites that cannot be explained by a known general medical condition. The nurse analyzes this as most closely related to the medical diagnosis of: A. somatoform disorder. B. pain syndrome. C. generalized anxiety disorder. D. obsessive-compulsive disorder.
A. somatoform disorder.
Rationale: These symptoms meet the DSM-IV-TR criteria for somatization disorder. 2. These symptoms are not associated with pain syndrome because there is no association with a medical condition. 3. GAD does not include complaints related to multiple organ systems. 4. Data do not support the presence of obsessions or compulsions.
A patient was driving an auto along a deserted country road when a moderate earthquake caused the bridge she was passing over to collapse, which inadvertently caused her to be trapped in her car for several hours. A year later she still has nightmares about the event, and reexperiences the feelings of fear and isolation associated with being trapped in the car in swirling water up to her neck. She avoids driving over bridges. She indicates that her relationships have not been "normal" since the event because she is so tense. The data collected are consistent with the symptoms of: A. agoraphobia B. panic attacks C. generalized anxiety disorder D. post-traumatic stress disorder
D. post-traumatic stress disorder
Rationale: PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event.
- Which piece of subjective data obtained during the nurse’s psychiatric assessment of a patient experiencing severe anxiety would indicate the possibility of posttraumatic stress disorder?
A. “I keep washing my hands over and over.”
B. “My legs feel weak most of the time.”
C. “I’m afraid to go out in public.”
D. “I keep reliving the rape.”
D. “I keep reliving the rape.”
Rationale: After a psychologically traumatic event, the person may reexperience the event via dreams or flashbacks.
When the nurse has diagnosed a patient as experiencing panic-level anxiety, an intervention that should be implemented immediately is to
A. teach relaxation techniques.
B. place the patient in four-point restraint.
C. reduce stimuli.
D. gather a show of force.
C. reduce stimuli.
Rationale: Patients experiencing panic-level anxiety are unable to focus on reality, ruling out option 1. Although the patient is completely disorganized, violence may not be imminent, ruling out options 2 and 4. Reducing stimuli is helpful because the patient is unable to screen stimuli. A simplified environment reduces demands on the patient and supports reintegration.
Which of the following is a criterion for evaluation of the anxiety level in patients with an anxiety disorder?
A. Ability to be assertive
B.Ability to determine appropriateness of own behavior
C.Attention span and concentration
D.Sleep pattern
C.Attention span and concentration
Rationale: The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate, severe, and panic-level anxiety. The other options are not relevant as evaluation criteria; for example, patients with anxiety disorders are often aware of the “oddness” of their symptoms. Anxiety level cannot be measured by assertiveness. Sleep pattern is not a reliable indicator of anxiety. One may have insomnia for reasons other than anxiety.
For planning purposes, the nurse caring for a patient with obsessive-compulsive disorder should know that an effective treatment for obsessive-compulsive disorder is A. analysis B. group therapy C. flooding D. clomipramine
D. clomipramine
Rationale: The medication clomipramine has been effective in reducing obsessive-compulsive behavior in a large number of patients with this disorder. The other treatment strategies have been evaluated as being less successful.
Which of the following interventions should the nurse incorporate in the care plan of a patient with dementia to support short-term memory? A. Daily activity schedule B. Activities using large muscles C. Simple word games D. A discussion group
A. Daily activity schedule
Rationale: A daily activity schedule helps remind the patient of what to do and when to do it. A written schedule helps support recent memory. Options 2, 3, and 4 are appropriate activities but do not directly address the support of recent memory.
A 45-year-old male has been admitted with a diagnosis of delirium of unknown etiology. The nurse would expect to assess: A. fluctuating level of consciousness. B. gait abnormalities. C. apathetic affect. D. negative thought content.
A. fluctuating level of consciousness.
Rationale: Disturbances of consciousness that tend to fluctuate during the course of the day are a primary symptom of delirium. The other options are not expected in delirium.
A patient with dementia is unable to name ordinary objects. Instead, he describes the function, for example, "the thing you cut meat with." The nurse should assess this as: A. apraxia. B. agnosia. C. aphasia. D. amnesia
B. agnosia.
Rationale: Agnosia is the failure to identify objects despite intact sensory function. 1. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. 3. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). 4. Amnesia is inability to remember a significant block of information.
Which of the following descriptions of patient experience and behavior can be assessed as an illusion? A patient
A. states, “I keep hearing a man’s voice telling me to run away.”
B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall.
C. becomes anxious whenever the nurse leaves her bedside.
D. tries to hit the nurse when vital signs are being taken.
B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall.
Rationale: An illusion is a misinterpreted sensory perception.
Which of the following would the nurse assess as an example of cognitive impairment?
A. Crying when the occasion calls for laughter
B. Inability to name a familiar object
C. Incontinence
D. Agitation
B. Inability to name a familiar object
Rationale: Inability to name an object is called agnosia. Naming an object requires a high level of cortical functioning. Agnosia is an example of cognitive impairment.
An action the nurse can advise a family to take in the home setting to enhance safety for the family member with Alzheimer’s disease is
A. placing throw rugs on tile or wooden floors.
B. instructing patient on cooking safety.
C. allowing patient to smoke unattended.
D. having patient wear an identification bracelet with name, address, and telephone number
D. having patient wear an identification bracelet with name, address, and telephone number
Rationale: Patients with Alzheimer’s disease are prone to wander. If the patient wanders out of the home, an identification bracelet will facilitate his or her safe return.
With respect to evaluation of outcomes and goals for the patient with Alzheimer’s disease, the nurse should be aware of the need for
A. changing expectations for the patient as patient abilities deteriorate.
B. identifying stressors that impact negatively on the patient.
C. simplifying the environment to reduce sensory perceptual alterations.
D. changing interventions when goals are unmet.
A. changing expectations for the patient as patient abilities deteriorate.
Rationale: A patient whose course of illness is predictably downward will need to have goals and outcomes correspondingly adjusted to lower levels. This is true of a patient with Alzheimer’s disease. Option 1 is the only one that deals with goal and outcome planning. Option 2 deals with assessment, and options 3 and 4 deal with interventions.
Which of the following is an appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction?
A. Employ negative responses to the behavior.
B. Use touch to communicate.
C. Eliminate or reduce environmental stimulation.
D.Maintain close personal boundaries.
C. Eliminate or reduce environmental stimulation.
Rationale: Reducing stimulation is calming and will allow the patient to focus his or her limited intellectual skills on regaining control. 1. Behavioral responses to the patient should be positive. 2. Touch can easily be misinterpreted as a threat. 4. Patients need increased personal space during catastrophic reactions.
The husband of a patient with moderately advanced Alzheimer’s disease tells the nurse his wife becomes greatly distressed several times a week as she tells him she sees strangers walking around in the house. She thinks these strangers are taking her things. The nurse should advise the husband to:
A. try to talk his wife out of these ideas by using logic.
B. try diverting her by suggesting an activity.
C. search the house with her and show her that no strangers are there.
D. put locks on doors and windows to increase her sense of security.
B. try diverting her by suggesting an activity.
Rationale: It is important not to reinforce hallucinations or delusions. A useful strategy is to listen briefly and then attempt to divert the individual by focusing on a real activity.
An objective sign that frequently accompanies the subjective symptoms of delirium is: A. reduced awareness. B. disorganized thinking. C. psychomotor retardation. D. disturbed sleep-wake cycle
D. disturbed sleep-wake cycle
Rationale: Patients with delirium often demonstrate day-night sleep reversal. Regarding option 1, awareness fluctuates. Regarding option 2, thinking matches level of awareness, with logical alternating with illogical. Regarding option 3, psychomotor agitation is often seen as plucking at the bed sheets or nightgown.
Which of the following nursing techniques are appropriate for successful interaction with a patient who has been diagnosed with Alzheimer’s disease
A. Giving all directions at one time to increase understanding
B. Correcting errors made by the patient by speaking to him in a loud, clear voice
C. Encouraging communication and maintaining a calm demeanor
D. Setting strict time limits and repeatedly rephrasing misunderstood questions
C. Encouraging communication and maintaining a calm demeanor
Rationale: These interventions will create a positive emotional climate and preserve patient self esteem. 1. Directions should be given in step-by-step fashion. 2. Activities should not be judged, and the patient should be addressed in a well-modulated voice. 4. Patients with dementia usually need increased time to perform a task, and direction should not be rephrased, only repeated.
The nurse notes that an elderly patient has fluctuating levels of awareness. She seems anxious. She tells the nurse she saw her granddaughter standing at the foot of the bed during the night. Later the nurse sees her moving her hands as though picking things out of the air. The nurse should suspect: A. delirium. B. dementia. C. bipolar disorder. D. schizophrenia
A. delirium
Rationale: The symptoms presented are consistent with the symptoms of delirium.
When the nurse gives anticipatory guidance to the family of a patient with early Alzheimer’s disease, which behavioral problem common to that stage of the disease should be mentioned?
A. Violent outbursts
B. Emotional disinhibition
C. Inability to carry on an in-depth conversation
D. Inability to eat and drink enough to meet body requirements
C. Inability to carry on an in-depth conversation
Rationale: Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.
In planning care for a newly admitted patient with depression, the highest priority for the nurse is:
A. orienting the patient to the unit.
B. encouraging expression of feelings.
C. providing a safe environment.
D. meeting the patient at an appropriate affective level
C. providing a safe environment.
Rationale: Safety is the highest priority. The other interventions are appropriate but of lesser importance than this basic need.
Which of the following is a priority assessment for the patient with major depression? A. Nutritional status B. Fluid and electrolyte balance C. Suicidal ideation D. Mood and affect
C. Suicidal ideation
Rationale: Safety needs take priority over the other needs listed as options. Assess presence of suicidal ideation and determine and implement means to provide patient safety.
A priority nursing intervention for a patient who underwent his first electroconvulsive therapy (ECT) treatment a half hour ago would be: A. monitoring vital signs. B. offering oral fluids. C. encouraging group interaction. D. evaluating ECT effectiveness.
A. monitoring vital signs.
Rationale: Stabilization of the patient is the priority; therefore monitoring vital signs would be the priority intervention. Other interventions would be appropriate at varying times post-ECT. 2. Fluids can be offered after the patient awakens and is able to be up, usually within 30 minutes to an hour after treatment. 3. The post-ECT patient is typically sleepy and confused and unable to participate in group activities for an hour or more. 4. ECT effectiveness is evaluated after several treatments.
A 60-year-old man who comes to the health clinic for his annual flu shot tells the nurse he feels tired all the time, finds little pleasure in things anymore, and has difficulty sleeping. The best nursing intervention would be to:
A. have him remain in the clinic until evaluated by a mental health professional.
B. instruct him in how to manage these typical complaints associated with aging.
C. explore his psychiatric history and further assess his current mental status.
D. explain that this is not a psychiatric clinic and provide a follow-up referral.
C. explore his psychiatric history and further assess his current mental status.
Rationale: The patient is demonstrating signs of depression that the nurse should explore further. 1. The nurse should perform a basic assessment before referring. 2. These are not typical signs of aging; they are indicative of depression. 4. The nurse should perform a mental status examination before referring.
To plan care for a patient with severe major depressive disorder, the nurse will make it a priority to:
A. avoid creating a stressful situation by asking for patient participation.
B. assess patient cognition and ability to participate in planning.
C. include teaching about the possibility of developing mania.
D. advise the patient that electroconvulsive therapy (ECT) may be indicated.
B. assess patient cognition and ability to participate in planning.
Rationale: Cognition may be impaired in major depression; the patient is encouraged to participate in care planning only to the extent of his or her capabilities. 1. Patients should have input into care planning to the greatest extent possible. 3. No evidence is given that mania is a concern. 4. ECT is a collaborative intervention to be determined with the physician.
What characteristic usually manifested by an individual during a manic episode can be used positively as a part of nursing intervention? A. Distractibility B. Clang association C. Flight of ideas D. Poor concentration
A. Distractibility
Rationale: Distractibility assists the nurse to direct the patient toward more appropriate, constructive activities.
What can a nurse do to avoid feelings of frustration when establishing a relationship and working with a severely depressed patient? Expect the patient to
A. be receptive to the plans for nursing care.
B. be withdrawn and disinterested in a relationship.
C. show signs of improvement after several scheduled sessions.
D. show gratitude for attention
B. be withdrawn and disinterested in a relationship.
Rationale: A depressed person often feels undeserving of the attention of health care staff. Patients often reject the overtures of staff and appear not to respond to nursing interventions.
A depressed patient who is receiving a tricyclic antidepressant tells the nurse, “My mood is a little better, but I’m so sleepy all the time that I can’t do much of anything.” The nurse should
A. tell the patient that the sleepiness will probably wear off in about 6 weeks.
B. suggest to the physician that the medication be administered in one bedtime dose.
C. withhold the drug until the physician examines the patient.
D. perform a mental status examination on the patient.
B. suggest to the physician that the medication be administered in one bedtime dose.
Rationale: Many tricyclic antidepressants can be given safely in a daily single dose. The drowsiness that is so annoying by day can help the patient’s sleep pattern.
The side effects of lithium the nurse can expect the patient to demonstrate when the serum lithium level is within the therapeutic range include:
A. extreme thirst and vomiting.
B. polyuria and fine hand tremor.
C. ataxia and orthostatic hypotension.
D. confusion, restlessness, and sleeplessness
B. polyuria and fine hand tremor.
Rationale: Because patients on lithium drink so much, polyuria is expected. A fine hand tremor is often present at therapeutic serum lithium levels. The other options present symptoms that are usually seen when the patient is experiencing lithium toxicity.
A student nurse caring for a depressed patient reads the following in the patient’s medical record: “This patient clearly shows the vegetative signs of depression.” What can the student expect to observe?
A. Suicidal ideation
B. Feelings of hopelessness, helplessness, and worthlessness
C. Constipation, anorexia, and sleep disturbance
D. Anxiety and psychomotor agitation
C. Constipation, anorexia, and sleep disturbance
Rationale: Vegetative signs of depression are alterations in body processes necessary to support life and growth.
Information given to a depressed patient and his or her family when the patient is begun on tricyclic antidepressant therapy should include
A. the need to avoid exposure to bright sunlight.
B. the fact that mood improvement may take 7 to 28 days.
C. instructions to restrict sodium intake to 1 g daily.
D. the need to maintain a tyramine-free diet.
B. the fact that mood improvement may take 7 to 28 days.
Rationale: Improvement in mood may not be noticed by the patient for 3 to 4 weeks, and the full effect may take 6 to 8 weeks. To avoid discouragement, the patient should frequently be reassured that the medication works slowly.
What initial nursing intervention is appropriate to take in the immediate post-electroconvulsive therapy (ECT) treatment period?
A. Place the patient in the lateral position.
B. Repeatedly stimulate the patient to respond.
C. Assist the patient to sit up, then ambulate.
D. Begin forcing fluids
A. Place the patient in the lateral position.
Rationale: During the immediate posttreatment period, the patient is recovering from general anesthesia. Placing patients on their side prevents aspiration in the event that the swallowing and gag reflexes are slow to return.
Seclusion is being considered for a severely hyperactive, aggressive manic patient. Which rationale explains the usefulness of this intervention?
A. It permits uninterrupted nursing intervention time with other patients.
B. It assists in limit setting, enabling the patient to learn to follow unit rules.
C. It is an effective way of protecting the patient until medication can take effect.
D. It provides reduction of environmental stimuli that impact negatively on the patient
D. It provides reduction of environmental stimuli that impact negatively on the patient
Rationale: Seclusion is used when less restrictive measures have failed to help the patient maintain control. One of its benefits is to reduce overwhelming environmental stimuli impacting on an extremely distractible individual.
A parameter that should be observed when planning activities for a manic patient is
A. promote group activities.
B. avoid competitive activities.
C. discourage solitary activities.
D. require attendance at the community meetings.
B. avoid competitive activities.
Rationale: Group and competitive activities provide more stimulation than is therapeutic for a manic patient. A quiet, nonstimulating environment is desirable.
