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NCLEX-RN PDF DEMO:
QUESTION NO: 1
A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
Answer: A
Explanation:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
QUESTION NO: 2
In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
Answer: B
Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B)
Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C)
Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D)
Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
QUESTION NO: 3
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.
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 1-2 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.
QUESTION NO: 4
Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
Answer: D
Explanation:
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.
QUESTION NO: 5
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D
Explanation:
(A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48-
96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
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Updated: May 27, 2022