NCLEX Select All That Apply Practice Exam 2 (10 Questions)

1. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client's history? Select all that apply.

Impulsiveness

Lability of mood

Ritualistic behavior

Psychomotor retardation

Self-destructive behavior

The nurse would expect the client's history to include impulsiveness, lability of mood, and self-destructive behavior. Borderline personality disorder is characterized by impulsive behavior, such as risky sexual behavior, substance abuse, or reckless driving. Lability of mood refers to rapid and extreme shifts in emotions, which is a common symptom in individuals with borderline personality disorder. Self-destructive behavior, such as self-harm or suicidal ideation, is also commonly seen in individuals with this disorder. Ritualistic behavior and psychomotor retardation are not typically associated with borderline personality disorder.

Explanation

The nurse would expect the client's history to include impulsiveness, lability of mood, and self-destructive behavior. Borderline personality disorder is characterized by impulsive behavior, such as risky sexual behavior, substance abuse, or reckless driving. Lability of mood refers to rapid and extreme shifts in emotions, which is a common symptom in individuals with borderline personality disorder. Self-destructive behavior, such as self-harm or suicidal ideation, is also commonly seen in individuals with this disorder. Ritualistic behavior and psychomotor retardation are not typically associated with borderline personality disorder.

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2. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

Inspect the insertion site for swelling, erythema, or drainage.

Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.

If unable to aspirate blood, reposition the client and encourage the client to cough.

Contact the health care provider about verifying placement if the status is questionable.

A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Explanation

A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

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3. Which of the following nursing interventions are written correctly? (Select all that apply.)

Apply continuous passive motion machine during day.

Perform neurovascular checks.

Elevate head of bed 30 degrees before meals.

Change dressing once a shift.

It is specific in what to do and when.

Explanation

It is specific in what to do and when.

4. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's outflow is less than the inflow. Select actions that the nurse should take.

Place the client in good body alignment

Check the level of the drainage bag

Contact the physician

Check the peritoneal dialysis system for kinks

Reposition the client to his or her side.

If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Explanation

If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

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5. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

Excess Fluid Volume

Imbalanced Nutrition; Less than Body Requirements

Activity Intolerance

Impaired Gas Exchange

Pain.

Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Explanation

Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

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6. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

Head tilt

Vomiting

Polydipsia

Lethargy

Increased appetite

Increased pulse

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Explanation

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

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7. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Elevate the HOB to 90 degrees

Loosen constrictive clothing

Use a fan to reduce diaphoresis

Assess for bladder distention and bowel impaction

Administer antihypertensive medication

Place the client in a supine position with legs elevated

The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Explanation

The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

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8. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Uterine enlargement

Fetal heart rate detected by nonelectric device

Outline of the fetus via radiography or ultrasound

Chadwick’s sign

Braxton Hicks contractions

Ballottement

The probable signs of pregnancy include:

Uterine Enlargement
Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6.
Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month
Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6.
Ballottement or rebounding of the fetus against the examiner’s fingers of palpation
Braxton-Hicks contractions
Positive pregnancy test measuring for hCG.

Positive signs of pregnancy include:

Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks
Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG
Active fetal movement palpable by the examiners
Outline of the fetus via radiography or ultrasound

Explanation

The probable signs of pregnancy include:

Uterine Enlargement
Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6.
Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month
Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6.
Ballottement or rebounding of the fetus against the examiner’s fingers of palpation
Braxton-Hicks contractions
Positive pregnancy test measuring for hCG.

Positive signs of pregnancy include:

Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks
Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG
Active fetal movement palpable by the examiners
Outline of the fetus via radiography or ultrasound

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9. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“If I limit my fluid intake I will not have to empty my ostomy pouch as often.”

“I can place an aspirin tablet in my pouch to decrease odor.”

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”

“I must use a skin barrier to protect my skin from urine.”

“I should empty my ostomy pouch of urine when it is full.”

The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

Explanation

The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

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10. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

The client functions well in other areas of his life.

The degree of aggressiveness is out of proportion to the stressor.

The violent behavior is most often justified by the stressor.

The client has a history of parental alcoholism and chaotic, abusive family life.

The client has no remorse about the inability to control his anger.

A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

Explanation

A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

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