NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:
Correct Answer: A
Rationale: Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
Question 2 of 5
Prior to an amniocentesis, a fetal ultrasound is done in order to:
Correct Answer: C
Rationale: Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus.
Question 3 of 5
The nurse is caring for a client with a history of bipolar disorder. Which medication is most likely to be prescribed for mood stabilization?
Correct Answer: B
Rationale: Lithium carbonate is a first-line mood stabilizer for bipolar disorder, preventing manic and depressive episodes. Fluoxetine treats depression, alprazolam is for anxiety, and methylphenidate is for ADHD.
Question 4 of 5
The nurse is caring for a client with a colostomy. Which finding requires immediate intervention?
Correct Answer: D
Rationale: A significantly protruding stoma may indicate prolapse, a complication requiring immediate intervention to prevent ischemia or obstruction. Pink stoma, cramping, and liquid stool are normal or less urgent.
Question 5 of 5
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Correct Answer: C
Rationale: This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. This answer is correct. Manipulative clients must abide by consistent rules. This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.