NCLEX-RN Quiz Part 14 (826-865)

NO.826 A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

A.            Displacement

B.            Projection

C.            Reaction formation

D.            Suppression

NO.827 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

A.            Small, frequent feedings of foods that can be carried

B.            Tube feedings with nutritional supplements

C.            Allowing him to eat when and what he wants

D.            Giving him a quiet place where he can sit down to eat meals

NO.828 When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4-8) of pregnancy is so critical.

A.            Duplication of genetic information takes place.

B.            Organogenesis occurs.

C.            Subcutaneous fat builds up steadily.

D.            Kidneys begin to secrete urine.

NO.829 Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:

A.            Parkinsonism and dystonia

B.            Dystonia and akathisia

C.            Akathisia and parkinsonism

D.            Neuroleptic malignant syndrome

NO.830 A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:

A.            Note the color and amount of fluid on her clothes.

B.            Assess the FHR.

C.            Notify the physician.

D.            Place the nitrazine test paper at the cervical os and note the color change.

NO.831 A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

A.            Must use the least restrictive measure possible to control the behavior

B.            Should put the client in seclusion until he promises to behave appropriately

C.            Should apply full restraints until the behavior is under control

D.            Should allow other clients to observe the acting out so that they can learn from the experience

NO.832 A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:

A.            Allow her privacy at mealtimes

B.            Praise her for eating everything

C.            Observe behavior for 1-2 hours after meals to prevent vomiting

D.            Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes

NO.833 The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:

A.            Encourage coughing and deep breathing each hour

B.            Obtain arterial blood gases

C.            Increase O2 from 2-3 L/min

D.            Remove the postoperative dressing to check for bleeding

NO.834 A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:

A.            Autonomic dysreflexia

B.            Bradycardia

C.            Central cord syndrome

D.            Spinal shock

NO.835 A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

A.            Below the umbilicus toward left side of mother's abdomen

B.            Below the umbilicus toward right side of mother's abdomen

C.            At the umbilicus

D.            Above the umbilicus to the left side of mother's abdomen

NO.836 A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

A.            Responsive to touch, wants to be held

B.            Uncomforted by touch, refuses bottle

C.            Maintains eye-to-eye contact

D.            Finicky eater, easily pacified, cuddly

NO.837 A dose of theophylline may need to be altered if a client with COPD:

A.            Is allergic to morphine

B.            Has a history of arthritis

C.            Operates machinery

D.            Is concurrently on cimetidine for ulcers

NO.838 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer

0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?

A.            Increased pulse rate

B.            Increased expectorate of secretions

C.            Decreased inspiratory difficulty

D.            Increased respiratory rate

NO.839 A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the:

A.            prothrombin time (PT)

B.            partial thromboplastin time (PTT)

C.            PTT-C

D.            Fibrin split products

NO.840 In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

A.            Clay-colored stools

B.            Steatorrhea stools

C.            Dark brown stools

D.            Blood-tinged stools

NO.841 A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

A.            Increase your oral intake of fluids to at least 4000 mL every day.

B.            Avoid contact with people who have contagious illnesses.

C.            Brush your teeth at least 4 times a day with a firm toothbrush.

D.            Immediately stop taking the prednisone if you feel depressed.

NO.842 In teaching the client about proper umbilical cord care, the nurse recommends that:

A.            Petrolatum be placed around the cord after the sponge bath

B.            A belly binder be applied to prevent umbilical hernia

C.            The area be cleansed at diaper changes with alcohol and inspected for redness or drainage

D.            The cord clamp be left on until the cord stump separates

NO.843 Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

A.            She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.

B.            She places her infant on her right side after feeding her.

C.            She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.

D.            She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.

NO.844 A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:

A.            "Call your physician if you develop palpitations, dizziness, or restlessness.''

B.            "Cigarette smoking may significantly increase the risk for theophylline toxicity.''

C.            "Take this medication on an empty stomach.''

D.            "Do not take your medicine if your pulse is less than 60 beats per minute.''

NO.845 A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?

A.            Gravida 4, para 2, ab 1

B.            Gravida 5, para 3, ab 1

C.            Gravida 5, para 4, ab 0

D.            Gravida 4, para 3, ab 0

NO.846 A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?

A.            Klebsiellapneumonia

B.            Pneumococcal pneumonia

C.            Legionella pneumophilapneumonia

D.            Escherichia colipneumonia

NO.847 A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

A.            Thioridazine (Mellaril), lithium, and benztropine

B.            Atropine, sodium brevitol, and succinylcholine chloride (Anectine)

C.            Sodium, potassium, and magnesium

D.            Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)

NO.848 A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be:

A.            "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.''

B.            "It is not too much trouble. This is the best way to manage urination.''

C.            "OK. I'll ask your physician if we can replace the Foley.''

D.            "You need to learn this because your doctor ordered it.''

NO.849 A laboratory technique specific for diagnosing Lyme disease is:

A.            Polymerase chain reaction

B.            Heterophil antibody test

C.            Decreased serum calcium level

D.            Increased serum potassium level

NO.850 A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?

A.            Smooth, coordinated voluntary movement

B.            Tremors

C.            Rigidity

D.            Muscle weakness

NO.851 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

A.            One centimeter below the ischial spines

B.            One centimeter above the ischial spines

C.            Has not entered the pelvic inlet yet

D.            Located in the pelvic outlet

NO.852 A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

A.            Crying

B.            Falling asleep

C.            Rolling from his back to his tummy

D.            Sucking his thumb

NO.853 Goal setting for a client with Meniere's disease should include which of the following?

A.            Frequent ambulation

B.            Prevention of a fall injury

C.            Consumption of three meals per day

D.            Prevention of infection

NO.854 A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

A.            10 weeks

B.            16 weeks

C.            20 weeks

D.            30 weeks

NO.855 Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

 A.           Report the findings to the physician

B.            Assist the client to do range of motion exercises

C.            Check the client's potassium level

D.            Administer the as-needed dose of phenytoin (Dilantin)

NO.856 A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?

A.            Short, polite responses to interview questions

B.            Introspection related to his present situation

C.            Exaggerated self-importance

D.            Feelings of helplessness and hopelessness

NO.857 A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor

and delivery are the ischial spines because:

A.            Ischial spines are the narrowest diameter of the pelvis

B.            Ischial spines are the widest diameter of the pelvis

C.            They represent the inlet of birth canal

D.            They measure pelvic floor

 

NO.858 A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?

A.            Oral poliovirus vaccine

B.            Inactivated poliovirus vaccine

C.            Tetanus toxoid

D.            Hepatitis B vaccine

NO.859 The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?

A.            Infuse volume at 44 mL/hr.

B.            Infuse volume at 22 mL/hr.

C.            Infuse volume at 10 mL/hr.

D.            Infuse volume at 30 mL/hr.

NO.860 A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

A.            Loss of ability to speak and communicate effectively

B.            Aspiration and weight loss

C.            Secondary infection resulting from poor oral hygiene

D.            Drooling

NO.861 The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:

A.            Call the physician and inform him that the client has expired.

B.            Remind the husband that the physician wrote an order not to resuscitate.

C.            Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.

D.            Call a code and proceed with cardiopulmonary resuscitation.

NO.862 A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?

A.            Emphasize those aspects of the procedure that require cooperation.

B.            Tell the child not to cry or yell.

C.            Tell the child that he will get a "stick" in his back.

D.            Use medical terminology when explaining the procedure to the client.

NO.863 Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

A.            Creatinine

B.            Sodium

C.            Calcium

D.            Potassium

NO.864 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

A.            Limit fluids to 500 mL/day.

B.            Administer 2 hours before meals.

C.            Observe for skin rash and diarrhea.

D.            Monitor blood pressure, pulse.

NO.865 The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:

A.            "It must be God's will and probably is for the best."

B.            "This must be a difficult time for you. Would you like to talk about it?"

C.            "I'm sure your other children will be a comfort for you."

D.            "Don't worry, you're still young. If I were you I'd just try again."