NCLEX RN Registered Nurses Quiz | Practice Test 10
1 >>An adult client, who is petitioning for release from a legal hold on a mental health unit, demonstrates care and consideration for other clients, complies with unit rules, and attends regular group meetings. According to Maslow, what level(s) has the client mastered? Select all that apply. ?
(A) Safety and security.
(B) Self-esteem.
(C) Self-actualization.
(D) Self-preservation.
2 >>An adolescent client, admitted for depression due to peer pressures and substance use, is unable to contract for safety. A nurse should recognize that this client is in Erikson's developmental stage of: ?
(A) Identity vs. role diffusion.
(B) Industry vs. inferiority.
(C) Intimacy vs. isolation.
(D) Ideality vs. reality.
3 >>A client is on lithium for management of bipolar disorder. Which signs and symptoms should indicate to a nurse that the client is at risk for severe toxicity? ?
(A) Lethargy and motor weakness.
(B) Hand tremors.
(C) Tardive dyskinesia.
(D) Pruritus.
4 >>A client's spouse reveals ongoing infidelity in their relationship. A nurse identifies that this client is at increased risk for: ?
(A) Ineffective protection.
(B) Pain.
(C) Injury.
(D) Knowledge deficit.
5 >>A nurse assesses an adolescent client in a psychiatric emergency department for suicidal ideation. The client's parents are preoccupied with divorce proceedings. Which problem should the nurse suspect that this client is experiencing? ?
(A) Oppositional defiant disorder related to parental separation.
(B) Acute traumatic stress disorder related to family stress.
(C) Mood disorder related to role reversal.
(D) Adjustment disorder related to parental separation.
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6 >>Clients who are dependent on alcohol and experience withdrawal are at risk for physical problems. Which independent nursing actions should be conducted during the detoxification phase when caring for this client? Select all that apply. ?
(A) Assess vital signs every 4 hours and as needed.
(B) Place the client on seizure and fall precautions.
(C) Administer benzodiazepines and anticonvulsants.
(D) Increase the intravenous rate to match serum sodium levels.
7 >>The client is prescribed risperidone (Risperdal) at discharge for treatment of bipolar disorder. A nurse should recognize that more teaching is needed when the client states: ?
(A) "I will call the physician if I have unusual movements."
(B) "I will not stop the medication when my voices have gone away."
(C) "I will pay close attention to my weight increases."
(D) "I will have my liver panel drawn every month."
8 >>A client, who has had several verbal outbursts and is pacing around a psychiatric unit, is at risk for assaultive behavior. Which verbal response by a nurse is most appropriate? ?
(A) "Do not get agitated; everything is safe here."
(B) "Please take a time-out in your room."
(C) "If you don't follow the rules, you will be put in seclusion."
(D) "Let me take your blood pressure. I think you are having a lot of anxiety."
9 >>A client, who is severely depressed, is unable to contract for safety. Which nurse would be most appropriate to care for this client? ?
(A) A charge RN with 17 years' experience in a psychiatric/ mental health unit who routinely takes a one- or twoclient assignment.
(B) An experienced medical-surgical float nurse who assists in break relief.
(C) A new graduate RN who has not cared for a client experiencing severe depression.
(D) An RN with 3 years' experience in a psychiatric/ mental health unit who has been on leave for 2 months.
10 >>A client on a medical-surgical unit is recovering from a suicide attempt and is now stable and anticipating discharge to an outpatient program. Which staff nurse is most appropriate to assign to this client? ?
(A) The LPN/LVN with 5 years' experience, supervised by an experienced nurse.
(B) The nurse who is assigned to a client who is high acuity.
(C) The RN with 3 years' experience who is assigned to admit and discharge clients.
(D) The RN who is a preceptor to the new graduate nurse who has 3 weeks of experience.
11 >>A nurse is conducting a health program regarding grief at a local community center. Considering the concepts related to loss, which client is most likely to experience an unsuccessful grief response? ?
(A) The adolescent who is irritable and testing limits with authority.
(B) The spouse who returns to work, but sobs daily during breaks.
(C) The young child experiencing the sudden death of a parent.
(D) The middle-aged adult who develops a gastric ulcer.
12 >>A nurse is caring for a client who is diagnosed with psychogenic diabetes insipidus. Which laboratory value is most indicative of this condition? ?
(A) Serum glucose of 65 mg/dL.
(B) Serum Na of 130 mEq/L.
(C) Serum Na of 300 mEq/L.
(D) Serum glucose of 129 mg/dL.
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13 >>A client's family reports clinical manifestations of hyperactivity, delusions of grandeur, impaired judgment, and inability to sit still during a meal. Which diagnosis should a nurse suspect? ?
14 >>A nurse's priority related to clients who are experiencing clinical manifestations of borderline personality disorder should be to: ?
(A) Increase therapeutic communication when the client exhibits intrusiveness.
(B) Set limits when the client exhibits threats of selfdamaging behaviors.
(C) Engage in one-to-one discussions about childhood experiences.
(D) Employ behavior modification using covert techniques.
15 >>A client was recently diagnosed with depression related to loss of a spouse. The client describes thinking constantly about the relationship and dreams of reconciliation even though the spouse is deceased. A nurse should document this as: ?
(A) Omnipotence.
(B) Isolation of affect.
(C) Fantasy.
(D) Regression.
16 >>A client is 1 day postoperative for a stereotactic brain procedure for relief of compulsive behavior. For which complication should a nurse observe this client? ?
(A) Altered level of consciousness.
(B) Immobility.
(C) Electrolyte imbalance.
(D) Infection.
17 >>An adolescent client is diagnosed with anorexia nervosa and discloses an incestuous relationship. Which is a nurse's most therapeutic response? ?
(A) "Tell me more about what happened when you were younger."
(B) "You will be okay, just keep on talking."
(C) "What kind of comfort food do you want tonight?"
(D) "Can you tell me how you feel about what happened?"
18 >>A registered nurse (RN) can best demonstrate empathy by: ?
(A) Revealing personal experiences with similar issues.
(B) Conveying genuine understanding of the client's problems.
(C) Identifying behavioral problems.
(D) Advising the client about better communication techniques.
19 >>In attempting to reduce acting-out behaviors by a child in a pediatric psychiatric unit, a brief therapeutic hold is implemented. An RN knows that a therapeutic hold means: ?
(A) Involuntary confinement of a child in a locked room for no more than 30 minutes.
(B) Physically holding a child, up to 30 minutes, to assist the child to calm down.
(C) Placement of a papoose-like device on a child who is out of control and acting out.
(D) Use of a padded room to confine a child who cannot behave in the therapeutic milieu.
20 >>A psychiatric nurse is assigned to care for multiple clients. Which client should the nurse assess first? ?
(A) The client with auditory hallucinations, who is responding to the voices with laughter.
(B) The client with hallucinations, who has increased blood pressure and heart rate.
(C) The client with suicidal ideations, who has a nonlethal plan.
(D) The client with superficial self-inflicted wounds to the wrists and arms.
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21 >>In evaluating a client's understanding of divalproex sodium (Depakote) during discharge teaching, a nurse should identify that the client requires additional teaching if the client states: ?
(A) "I will need to get my complete blood count tested frequently."
(B) "I will take this medication the same time each day."
(C) "I will report any unusual bleeding to my doctor."
(D) "It is important to use sunscreen when taking this medication."
22 >>Which actions should a nurse include when developing a care plan for a client with problems associated with body image disturbance? Select all that apply. ?
(A) Provide the client with detailed plans for the future.
(B) Support the client with a realistic appraisal of the situation.
(C) Explore the client's strengths and available resources.
(D) Encourage the client to focus on the specific limitations.
23 >>Considering the development of egocentrism, which clients are most likely to experience egocentrism? Select all that apply. ?
(A) The adolescent with addiction to weight loss products.
(B) The infant fixated on the black-and-white figures.
(C) The elderly client with a history of substance abuse.
(D) The hospitalized toddler having a tantrum.
24 >>A nurse is required to provide limit setting on a pediatric mental health unit. What are the most important concepts related to limit setting? Select all that apply. ?
(A) Provide unit information to clients upon admission.
(B) Remove all contraband and employ frequent inspections.
(C) Stop destructive behavior immediately.
(D) Reinforce dependent behaviors with earned privileges.
25 >>A nurse is caring for a client who is experiencing serotonin syndrome. Which serotonergic drugs should a nurse recognize as possibly contributing to this problem? Select all that apply. ?
(A) Duloxetine (Cymbalta).
(B) Fluoxetine (Prozac).
(C) Aripiprazole (Abilify).
(D) Haloperidol (Haldol).
26 >>A client with antisocial personality disorder has been acting very manipulative. Which actions by a nurse will help to reduce the manipulative behaviors? Select all that apply. ?
(A) Develop a list of realistic goals with the client.
(B) Accept small tokens of appreciation as collaboration.
(C) Maintain consistent limit setting.
(D) Place the client on the "problem" board to modify behaviors.
27 >>A client was admitted yesterday with a diagnosis of acute traumatic stress disorder. What should a nurse expect this client's assessment to reveal? Select all that apply. ?
(A) Increased intimacy.
(B) Amnesia.
(C) Flashbacks.
(D) Expressions of guilt.
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28 >>Which clinical manifestations should a nurse recognize as being related to the "negative" symptoms associated with a schizophrenic client? Select all that apply. ?
(A) Brief, empty responses.
(B) Clang associations.
(C) Inappropriate sexual behaviors.
(D) Poor eye contact.
29 >>A client, who is manic, is at risk for nutritional deficits. Which nutritional products should the nurse encourage this client to select? Select all that apply. ?
(A) Fresh fruits and vegetables.
(B) Protein booster shake.
(C) Bean and cheese mini-tacos.
(D) Chocolate ice cream sundae.
30 >>The parent of the client with attention deficit-hyperactivity disorder (ADHD) is receiving discharge teaching for methylphenidate (Ritalin). A nurse evaluates that the parent is in need of additional teaching when the parent states: Select all that apply. ?
(A) "I must give my child the medication 30 minutes before meals."
(B) "My child will need to take this medication in the morning."
(C) "I would know that it indicates tolerance if my child gains weight."
(D) "It is best for my child to avoid caffeine with this medication."
31 >>A clinical nurse specialist describes behavior modification techniques to a group of new graduates. Which therapies should the clinical nurse specialist include in this description? Select all that apply. ?
(A) Free association.
(B) Cognitive-based therapy.
(C) Desensitization.
(D) Token economy.
32 >>A client, who abuses alcohol, is at risk for injury during the detoxification phase of alcohol withdrawal. Which physician order for this client should the nurse question? ?
(A) Apply soft wrist restraints as needed.
(B) Bedrest with side rails up.
(C) Maintain IV D5 0.45% NS at 100 mL/hr.
(D) Baseline ECG.
33 >>A client is responding with hostility to staff and other clients. A nurse's priority diagnosis for this client should be: ?
(A) Distorted sensory perception.
(B) Impaired social interaction.
(C) Risk for violence.
(D) Impaired thought processes.
34 >>When caring for a client who has been raped, which action should a nurse take first? ?
(A) Explore legal issues and prosecution.
(B) Acknowledge client's anxiety and fear.
(C) Explore client's feelings about recovery.
(D) Introduce defensive tactics.
35 >>A primary prevention measure that should be implemented by a nurse when working with clients who are at risk for elder abuse is: ?
(A) Reporting a case to law enforcement officials.
(B) Referring caregivers to community resources.
(C) Offering counseling to the victim.
(D) Providing the elder with hotline numbers.
36 >>A nurse suspects that a client may be experiencing anorexia nervosa. Which statement by the client's family supports the nurse's suspicion? ?
(A) "She spends so much time in the bathroom."
(B) "She plans the meals and counts calories."
(C) "She has stopped menstruating."
(D) "She is always oversalting her foods."
37 >>A long-term care client, diagnosed with Alzheimer's disease, is having difficulties with changes in daily routine and attempts to call family members at all hours and is no longer able to walk unassisted. Which problem should a nurse document as priority? ?
(A) Relocation stress syndrome.
(B) Altered attention and memory.
(C) Sensory/perceptual alterations.
(D) Risk for trauma.
38 >>A client, who has abused alcohol for 20 years, is admitted to a rehabilitation unit. Which laboratory values should a nurse expect to find? ?
(A) Decreased total protein and increased albumin.
(B) Increased blood alcohol levels and impaired reflexes.
(C) Increased LDH and amylase and decreased albumin.
(D) Decreased potassium and increased magnesium.
39 >>Which nursing assessments should indicate to a nurse that a newly admitted client is in amphetamine withdrawal? ?
(A) Apprehension, tremors, and psychosis-delirium.
(B) Insomnia, anxiety, and loss of appetite.
(C) Vomiting, tremors, and diaphoresis.
(D) Depression, lack of energy, and somnolence.
40 >>A client whispers, "The spiders are coming out of the vents; we need to move." Which response by a nurse demonstrates the therapeutic technique of focusing on reality? ?
(A) "I didn't understand you. Can you repeat that?"
