NCLEX Nursing Exam Questions!

1. The client said "I can't even take care of my baby. I'm good for nothing." Which is the appropriate nursing diagnosis?

Ineffective individual coping related to loss.

Impaired verbal communication related to inadequate social skills.

Low esteem related to failure in role performance

Impaired social interaction related to repressed anger.

This indicates the client’s negative self-evaluation. A sense of worthlessness may accompany depression.Options A. B. and D are not relevant. The cues do not indicate inability to use coping resources. decreased ability to transmit/process symbols. nor insufficient quality of social exchange

Explanation

This indicates the client’s negative self-evaluation. A sense of worthlessness may accompany depression.Options A. B. and D are not relevant. The cues do not indicate inability to use coping resources. decreased ability to transmit/process symbols. nor insufficient quality of social exchange

2. Which is the best indicator of success in the long term management of the client?

His symptoms are replaced by indifference to his feelings

He participates in diversionary activities.

He learns to verbalize his feelings and concerns

He states that his behavior is irrational.

The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors.Option A: The client is encouraged to acknowledge feelings rather than being indifferent to her feelingsOption B: Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success.Option D: Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor. not as irrational.

Explanation

The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors.Option A: The client is encouraged to acknowledge feelings rather than being indifferent to her feelingsOption B: Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success.Option D: Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor. not as irrational.

3. Which is the highest priority in the post-ECT care?

Observe for confusion

Monitor respiratory status

Reorient to time. place and person

Document the client’s response to the treatment

A side effect of ECT which is life threatening is a respiratory arrest.Options A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.

Explanation

A side effect of ECT which is life threatening is a respiratory arrest.Options A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.

4. Situation: A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding. arrogant. talked fast and hyperactive. Initially. the nurse should plan this for a manic client:

Set realistic limits to the client’s behavior

Repeat verbal instructions as often as needed

Allow the client to get out feelings to relieve tension

Assign a staff to be with the client at all times to help maintain control

The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety.Option B: Clear. concise directions are given because of the distractibility of the client but this is not the priority.Option C: The manic client tend to externalize hostile feelings. however only non-destructive methods of expression should be allowed.Option D: Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.

Explanation

The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety.Option B: Clear. concise directions are given because of the distractibility of the client but this is not the priority.Option C: The manic client tend to externalize hostile feelings. however only non-destructive methods of expression should be allowed.Option D: Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.

5. The nurse exemplifies an awareness of the rights of a client whose anger is escalating by:

Taking a directive role in verbalizing feelings

Using an authoritarian. confrontational approach

Putting the client in a seclusion room

Applying mechanical restraints

The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger.Option B: This is a threatening approach.Options C and D: Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.

Explanation

The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger.Option B: This is a threatening approach.Options C and D: Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.

6. A client on Lithium has diarrhea and vomiting. What should the nurse do first:

Recognize this as a drug interaction

Give the client Cogentin

Reassure the client that these are common side effects of lithium therapy

Hold the next dose and obtain an order for a stat serum lithium level

Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld. and a test is done to validate the observation.Option A: The manifestations are not due to drug interaction.Option B: Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics.Option C: The common side effects of Lithium are fine hand tremors. nausea. polyuria and polydipsia.

Explanation

Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld. and a test is done to validate the observation.Option A: The manifestations are not due to drug interaction.Option B: Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics.Option C: The common side effects of Lithium are fine hand tremors. nausea. polyuria and polydipsia.

7. The client is arrogant and manipulative. In ensuring a therapeutic milieu. the nurse does one of the following:

Agree on a consistent approach among the staff assigned to the client.

Suggest that the client take a leading role in the social activities

Provide the client with extra time for one on one sessions

Allow the client to negotiate the plan of care

A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed.Option B: This is not therapeutic because the client tends to control and dominate others.Option C: Limits are set for interaction time.Option D: Allowing the client to negotiate. may reinforce a manipulative behavior.

Explanation

A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed.Option B: This is not therapeutic because the client tends to control and dominate others.Option C: Limits are set for interaction time.Option D: Allowing the client to negotiate. may reinforce a manipulative behavior.

8. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident. The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is:

“I feel envious of mothers who have toddlers”

“I haven’t been able to open the door and go into my baby’s room “

“I watch other toddlers and think about their play activities and I cry.”

“I often find myself thinking of how I could have prevented the death.

This indicates denial. This defense is adaptive as an initial reaction to loss but an extended. unsuccessful use of denial is dysfunctional.Option A: This indicates acknowledgment of the loss. Expressing feelings openly is acceptable.Option C: This indicates the stage of depression in the grieving process.Option D: Remembering both positive and negative aspects of the deceased love one signals successful mourning.

Explanation

This indicates denial. This defense is adaptive as an initial reaction to loss but an extended. unsuccessful use of denial is dysfunctional.Option A: This indicates acknowledgment of the loss. Expressing feelings openly is acceptable.Option C: This indicates the stage of depression in the grieving process.Option D: Remembering both positive and negative aspects of the deceased love one signals successful mourning.

9. The following medications will likely be prescribed for the client EXCEPT:

Prozac

Tofranil

Parnate

Zyprexa

This is an antipsychotic.Option A: Prozac is a SSRI antidepressant.Option B: Tofranil antidepressant belongs to the Tricyclic group.Option C: Parnate is a MAOI antidepressant.

Explanation

This is an antipsychotic.Option A: Prozac is a SSRI antidepressant.Option B: Tofranil antidepressant belongs to the Tricyclic group.Option C: Parnate is a MAOI antidepressant.

10. An activity appropriate for the client is:

Table tennis

Painting

Chess

Cleaning

The client’s excess energy can be rechanneled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension.Option A: Tennis is a competitive activity which can stimulate the client.

Explanation

The client’s excess energy can be rechanneled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension.Option A: Tennis is a competitive activity which can stimulate the client.