NCLEX/ HESI
- 1.
A nurse is caring for a patient who has anxiety attacks. The nurse knows that the patient is experiencing a severe anxiety attack when:
- A.
The patient has feeling of impending doom.
- B.
The patient has decreased perceptions.
- C.
The patient has increased motivation.
- D.
The patient could cause harm to self or others.
Correct Answer
A. The patient has feeling of impending doom. -
- 2.
The LPN/LVN is caring for an older adult who was admitted to the long-term care facility 2 months previously. Three weeks ago his son was killed in a car accident. The patient has been staying in his room and not attending meals or activities. The highest priority nursing diagnosis for this patient is:
- A.
Hopelessness related to relocation to nursing home
- B.
Social isolation related to depression
- C.
Ineffective coping related to the number of recent losses
- D.
Grieving related to loss of son
Correct Answer
C. Ineffective coping related to the number of recent losses -
- 3.
Of the events listed, which one may precipitate feelings of anxiety?
- A.
Threats to self-esteem
- B.
Encouragement in physical strengths
- C.
Threats to those around us
- D.
Emotional growth
Correct Answer
A. Threats to self-esteem -
- 4.
A patient who has just been sexually assaulted has come to the emergency department. The patient is very calm and quiet. The nurse identifies this behavior as part of which defense mechanism?
- A.
Suppression
- B.
Rationalization
- C.
Projection
- D.
Denial
Correct Answer
D. Denial -
- 5.
One of the most common abuses among older adults is:
- A.
Drug abuse
- B.
Alcohol abuse
- C.
Emotional abuse
- D.
Physical abuse
Correct Answer
B. Alcohol abuse -
- 6.
Identify the common behaviors seen with illness.
- A.
Withdrawal
- B.
Shock
- C.
Questioning
- D.
Acceptance
- E.
Forgiveness
- F.
Anxiety
Correct Answer(s)
A. Withdrawal
B. Shock
F. Anxiety -
- 7.
With dyskinesia, the nurse would see:
- A.
Involuntary movements of the mouth and tongue
- B.
Abnormal breathing
- C.
Severe flushing, headache, and tremors
- D.
Migraine headache, hypertension
Correct Answer
A. Involuntary movements of the mouth and tongue -
- 8.
An adolescent who has a history of not getting along with others in school and lies to his mother about fighting and being in trouble so that he can drive the car is an example of which personality disorder?
- A.
Paranoid personality
- B.
Borderline personality
- C.
Antisocial personality
- D.
Dependent personality
Correct Answer
C. Antisocial personality -
- 9.
A nurse is caring for an older adult who lives in a long-term care facility on the Alzheimer's unit. Every evening around 5:00 PM the resident becomes increasingly agitated and more confused, a state that lasts throughout the evening. The nurse recognizes this behavior as:
- A.
Dementia
- B.
Delirium
- C.
Personality disorder
- D.
Sundowning syndrome
Correct Answer
D. Sundowning syndrome -
- 10.
A group of psychotic disorders characterized by severe and inappropriate emotional responses, by prolonged and persistent disturbances of mood and related thought distortions is called:
- A.
Anxiety disorders
- B.
Thought process disorders
- C.
Mood disorders
- D.
Personality disorders
Correct Answer
C. Mood disorders -
- 11.
A nurse working on a psychiatric unit knows that there are different therapeutic techniques used. The key component to psychiatric-mental health treatment is:
- A.
Working to resolve mental issues through therapeutic communication
- B.
The development of a helping-trusting relationship
- C.
That information that the patient shares is only known by one individual on the health care team
- D.
Therapeutic communication is not a necessary part of treatment.
Correct Answer
A. Working to resolve mental issues through therapeutic communication -
- 12.
The nurse is working on a psychiatric unit where a 6-year-old child has been admitted for treatment. The nurse uses toys to play with the child to help him express his feelings. This is an example of:
- A.
Cognitive therapy
- B.
Group therapy
- C.
Play therapy
- D.
Behavior therapy
Correct Answer
C. Play therapy -
- 13.
A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which nursing diagnosis as the highest priority?
- A.
Deficient knowledge related to lack of information regarding the procedure
- B.
Disturbed thought process related to temporary memory loss
- C.
Disturbed thought process related to confusion
- D.
Anxiety related to uncertainty of the events of the test.
Correct Answer
D. Anxiety related to uncertainty of the events of the test. -
- 14.
Excessive use or abuse, display of psychologic disturbance, decline of social and economic function and uncontrollable consumption indicating dependence are the four element that define:
- A.
Alcoholism
- B.
Addiction
- C.
Abuse
- D.
Addictive personality
Correct Answer
B. Addiction -
- 15.
A nurse is caring for a patient who has stopped drinking and runs the risk of alcohol withdrawal syndrome. The nurse monitors the patient knowing that tremors from alcohol cessation are usually seen how soon after cessation?
- A.
Within a few hours
- B.
Within 2 days
- C.
Within 1 week
- D.
Within 2?3 weeks
Correct Answer
A. Within a few hours -
- 16.
You have been assigned a patient who abuses alcohol. The patient is at risk for DTs (Delirium tremens). While monitoring the patient, which of the following signs would alert you to DTs?
- A.
Hypotension, coarse hand tremors, agitation
- B.
Stupor, agitation, muscle rigidity
- C.
Hypotension, ataxia, vomiting
- D.
Elevated temperature, changes in LOC, hallucinations
Correct Answer
D. Elevated temperature, changes in LOC, hallucinations -
- 17.
A patient is having trouble abstaining from alcohol. Which drug is often prescribed to encourage abstinence?
- A.
Librium (chlordiazepoxide)
- B.
Thorazine (chlorpromazine)
- C.
Antabuse (disulfiram)
- D.
Wellbutrin (bupropion)
Correct Answer
C. Antabuse (disulfiram) -
- 18.
Which of the following drugs gained notoriety in the 1990s, is associated with club drug use, and is often call the "date-rape" drug?
- A.
GHB (gamma-hydroxybutyrate)
- B.
Opioid analgesic heroin
- C.
Rohypnol (flunitrazepam)
- D.
Morphine
Correct Answer
C. Rohypnol (flunitrazepam) -
- 19.
The success of a patient going through a substance abuse treatment program depends on
- A.
The motivation of the user
- B.
The type of assistance received while in the program
- C.
The treatment plan established by the physician
- D.
The effectiveness of group therapy
Correct Answer
A. The motivation of the user -
- 20.
The health care system is the complete network of agencies, facilities, and all providers of health care in a specified geographic area. Of the following four statements, which one is the best description of the major goal of the health care system?
- A.
Provide care for those who are ill or injured.
- B.
Achieve optimal levels of health care for a defined population through adequate and appropriate health care services.
- C.
Provide diagnostic services to those who can afford it or who have health insurance.
- D.
Achieve standards of practice for all those who work within the health care system in providing care for the critically ill.
Correct Answer
B. Achieve optimal levels of health care for a defined population through adequate and appropriate health care services. -
- 21.
Maslow's Hierarchy of Needs was developed in the 1940s. Its main purpose is to:
- A.
Identify the basic human needs within health care
- B.
Provide the scope of practice for nurses.
- C.
Help nurses understand a patient’s placement on the illness/wellness continuum.
- D.
Assist in developing the patient’s bill of rights
Correct Answer
C. Help nurses understand a patient’s placement on the illness/wellness continuum. -
- 22.
The term for injury to a person or the person's property that gives rise to a basis for a legal action against the person who caused the damage is:
- A.
Assault.
- B.
Harm
- C.
Malpractice
- D.
Negligence
Correct Answer
B. Harm -
- 23.
Once a nurse is licensed, he or she can apply to another state for licensure by:
- A.
Applying to take the NCLEX® examination in that state
- B.
Interstate compact
- C.
Endorsement
- D.
Following the Nurse Practice Act
Correct Answer
C. Endorsement -
- 24.
When caring for patients, the nurse knows that part of the ethical principles include all patients having the same right to nursing interventions. This principle is:
- A.
Autonomy
- B.
Nonmaleficence
- C.
Justice
- D.
Beneficence
Correct Answer
C. Justice -
- 25.
Which of the following nonverbal communication techniques is very therapeutic and effective but requires a conscious effort by the nurse to practice and acquire skill in the use of this technique?
- A.
Listening
- B.
Silence
- C.
Touch
- D.
Conveying acceptance
Correct Answer
B. Silence -
- 26.
Which of the following is an example of nonverbal communication?
- A.
Moaning
- B.
Speaking
- C.
Writing
- D.
Reading
Correct Answer
A. Moaning -
- 27.
Therapeutic communication is a key to providing the best care possible to your patients. Select all the factors that affect therapeutic communication.
- A.
Language barrier
- B.
The environment
- C.
Level of trust
- D.
Culture
Correct Answer(s)
A. Language barrier
B. The environment
C. Level of trust
D. Culture -
- 28.
While assessing a patient's lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it last for more than 1 minute before the shape returns. The nurse would document this edema as: A.
- A.
4+ pitting edema
- B.
3+ pitting edema
- C.
2+ pitting edema
- D.
1+ pitting edema
Correct Answer
B. 3+ pitting edemaExplanation
3+ pitting edema is noticeably deep pitting, full and edematous extremity, with depression lasting more than 1 minute
4+ pitting edema is very deep pitting, very edematous and distorted extremity, with depression lasting as long as 2 to 5 minutes.
2+ pitting edema is somewhat pitting edema, no marked change in shape of the extremity, and depression disappears in 10-15 seconds.
Incorrect (4): 1+ pitting edema is slight pitting, no visible change in the shape of the extremity and depression disappears rapidly.Rate this question:
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- 29.
The role of the Licensed Practical Nurse in writing a nursing diagnosis is:
- A.
To assist with the determination of accurate nursing diagnosis
- B.
To leave the writing of the nursing diagnosis to the RN
- C.
To be responsible for writing the nursing diagnosis
- D.
Not involved in the nursing process
Correct Answer
A. To assist with the determination of accurate nursing diagnosis -
- 30.
Which of the following nursing orders is written correctly for the diagnosis of: Acute pain r/t deep vein thrombosis m/b redness, swelling, warmth, positive Homan's?
- A.
Assess level of pain
- B.
Complete bed rest with right leg elevated on two pillows at all times.
- C.
Monitor lab values.
- D.
Assess vital signs.
Correct Answer
B. Complete bed rest with right leg elevated on two pillows at all times. -
- 31.
Since the patient's medical record is a legal document, the nurse know that it is important to chart
- A.
In a very detailed, defensive manner
- B.
As little as possible so as to not incriminate yourself
- C.
Only what the patient says
- D.
Only the abnormal activities that occur
Correct Answer
A. In a very detailed, defensive manner -
- 32.
When charting by exception, which acronym is generally used?
- A.
SOAPE
- B.
SOAPIER
- C.
PIE
- D.
DARE
Correct Answer
C. PIE -
- 33.
You are caring for an older adult resident in a long-term care facility. While talking with this resident, you notice him reminiscing about his life and family and all the accomplishments in his career. Based on Erikson's stages you know this resident is in which stage?
- A.
Intimacy versus isolation
- B.
Generativity versus stagnation
- C.
Identity versus role confusion
- D.
Ego integrity versus despair
Correct Answer
D. Ego integrity versus despair -
- 34.
Young mother comes to the clinic with her 2-month-old daughter. While taking vital signs, the nurse reports the baby's heart rate is 120 beats per minute. The mother expresses concern about the fast heart rate. What is the best response by the nurse?
- A.
“Her pulse is okay for her age.”
- B.
“Don’t worry; I’ll let the physician know.”
- C.
“Has your daughter been having trouble breathing?”
- D.
“A normal heart rate for a 2 month old is 120 beats per minute.”
Correct Answer
D. “A normal heart rate for a 2 month old is 120 beats per minute.” -
- 35.
A mother tells the nurse that her 3-year-old son has been acting out against others and throwing temper tantrums. The most important instruction to this mother is:
- A.
Punish your son every time he says “no” to change his behavior
- B.
Set limits on your son’s behavior.
- C.
Ignore your son when he acts out.
- D.
Allow the behavior because it is normal at this age.
Correct Answer
B. Set limits on your son’s behavior. -
- 36.
According to Piaget, during the adolescent phase of growth and development, an individual's cognitive function reaches maturity. Piaget describes this stage as:
- A.
Preoperational phase
- B.
Concrete operational phase
- C.
Formal operational phase
- D.
Formal operational thought phase
Correct Answer
D. Formal operational thought phase -
- 37.
Because of the gradual physical changes that occur during middle adulthood (ages 40–65), women are at the highest risk for:
- A.
Heart disease
- B.
Osteoporosis
- C.
Respiratory problems
- D.
Diabetes
Correct Answer
B. Osteoporosis -
- 38.
During patient care of an older adult, the nurse is trying to build the nurse-patient relationship. Which of the following activities performed by the nurse will encourage reminiscence in the patient?
- A.
Having time spent visiting pets
- B.
Displaying calendars and clocks
- C.
Having a story-telling time
- D.
Encouraging patient to participate in activity of choice
Correct Answer
C. Having a story-telling time -
- 39.
Loss is a natural part of our lives. The loss that is felt when one leaves home for college is an example of:
- A.
Situational loss
- B.
Perceived loss
- C.
Maturational loss
- D.
Personal loss
Correct Answer
C. Maturational loss -
- 40.
The purpose of palliative care for a patient with a terminal illness is to:
- A.
Do no treatment and let nature take its course by following a patient’s DNR status.
- B.
Take decision-making ability away and give it to the power of attorney.
- C.
Place the patient in long-term care to receive 24-hour care.
- D.
Provide prevention, relief, reduction, or soothing of symptoms of a disease without providing a cure.
Correct Answer
D. Provide prevention, relief, reduction, or soothing of symptoms of a disease without providing a cure. -
- 41.
As a nurse caring for a dying patient, you know that there are changes in vital signs. While doing your assessment, you would note the patient's vital signs to be:
- A.
Fast, bounding pulse; lowered blood pressure; abnormally slow respirations
- B.
Slow, weak and thready pulse; lowered blood pressure; rapid, shallow, irregular respirations.
- C.
Fast, bounding pulse; increased blood pressure; rapid, shallow, irregular respirations.
- D.
Slow, weak, and thready pulse; increased blood pressure; rapid, shallow, irregular respirations.
Correct Answer
B. Slow, weak and thready pulse; lowered blood pressure; rapid, shallow, irregular respirations. -
- 42.
You are caring for a dying mother of a 6-year-old child. Based on the developmental age of the child, what beliefs might the child be feeling?
- A.
Believes that death is reversible
- B.
Seldom thinks about death
- C.
Believes wishes can be responsible for death
- D.
Expresses fear of death
Correct Answer
C. Believes wishes can be responsible for death -
- 43.
When caring for a patient needing wound care, your first step is to:
- A.
Wash your hands.
- B.
Explain the procedure to the patient
- C.
Assemble all equipment and supplies
- D.
Check the medical record for the physician’s orders
Correct Answer
D. Check the medical record for the physician’s orders -
- 44.
You are the nurse caring for a patient with a wound on the right arm. The wound is covered by a bandage. When assessing the skin that is distal to the bandage, you would assess for signs of:
- A.
Circulatory impairment
- B.
Inflammation
- C.
Bacteria
- D.
Impaired skin integrity
Correct Answer
A. Circulatory impairment -
- 45.
If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?
- A.
Sit the patient up to a semi-Fowler’s position.
- B.
Apply a pillow to the incision with slight pressure.
- C.
Roll the patient to the left side
- D.
Offer the patient a drink of water.
Correct Answer
B. Apply a pillow to the incision with slight pressure. -
- 46.
When removing staples from a surgical incision, which of the following interventions is most appropriate?
- A.
Remove every other staple, then wait several days to remove the rest.
- B.
Remove the middle staples first, then proceed to the outer edges, and apply dressing
- C.
Remove all the staples. If edges pull apart, apply steri-strips.
- D.
Remove every other staple first and replace with steri-strips while monitoring that incision remains closed.
Correct Answer
D. Remove every other staple first and replace with steri-strips while monitoring that incision remains closed. -
- 47.
The physician has ordered a sterile dry dressing change. The most appropriate way to cleanse the wound and surrounding area is to:
- A.
Use a sterile swab to soak up any drainage, then apply a clean dressing
- B.
Using an aseptic swab, start from the incision outward, one stroke per swab, then allow to air dry.
- C.
Using an aseptic swab, start at the top of the incision, using the same swab until dirty, then get a clean swab.
- D.
Using an aseptic swab, start on the side of the wound closest to you, one stroke per swab
Correct Answer
B. Using an aseptic swab, start from the incision outward, one stroke per swab, then allow to air dry. -
- 48.
The physician has ordered for your patient's leg wound to be irrigated using an antiseptic solution. To reduce the chance of contamination you would:
- A.
Direct the solution toward unhealthy tissue to healthy tissue within the wound.
- B.
Place the tip of the syringe touching the area needing to being cleaned.
- C.
Have the solution flow from the least contaminated to the most contaminated area
- D.
Instill the solution with force to remove any debris quickly from the wound.
Correct Answer
C. Have the solution flow from the least contaminated to the most contaminated area -
- 49.
A patient has come to the PACU after hip replacement surgery. Following your assessment, you need to set up a plan of care. The highest priority nursing diagnosis would be:
- A.
Tissue perfusion, ineffective
- B.
Nutrition: less than body requirements, imbalanced
- C.
Nutrition: more than body requirements, imbalanced
- D.
Skin integrity, impaired
Correct Answer
D. Skin integrity, impaired -
- 50.
While reviewing fire safety, a type C fire extinguisher can only be used on which type of fire?
- A.
A fire caused by a flammable liquid
- B.
An electrical fire
- C.
Paper, wood, or cloth fire
- D.
Any type of fire
Correct Answer
B. An electrical fire -
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Mar 21, 2022Quiz Edited by
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Sep 22, 2011Quiz Created by
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