NCLEX-PN Test Prep - 1. A client hospitalized with severe depression...

2022/2023 NCLEX-PN Test Prep

1(ONE)

Questions and Answers with Explanations

• A client hospitalized with severe depression and suicidal ideation refuses

to talk with the nurse. The nurse recognizes that the suicidal client has

difficulty:

• Expressing feelings of low self-worth
• Discussing remorse and guilt for actions
• Displaying dependence on others
• Expressing anger toward others

Answer D: The suicidal client has difficulty expressing anger toward others.

The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect.

• A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to

increase her dietary intake of potassium. The best snack for the client

requiring increased potassium is:

• Pear
• Apple
• Orange
• Banana

Answer D: Answers A, B, and C are incorrect because they contain lower

amounts of potassium. (Note that the banana contains 450mg K+, the orange contains 235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.)

• The nurse is caring for a client following removal of the thyroid.

Immediately post-op, the nurse should:

• Maintain the client in a semi-Fowler’s position with the head and neck

supported by pillows

• Encourage the client to turn her head side to side, to promote drainage

of oral secretions

• Maintain the client in a supine position with sandbags placed on either

side of the head and neck

• Encourage the client to cough and breathe deeply every 2 hours, with

the neck in a flexed position

Answer A: Following a thyroidectomy, the client should be placed in semiFowler’s position to decrease swelling that would place pressure on the airway. Answers B, C, and D are incorrect because they would increase the chances of post-operative complications that include bleeding, swelling, and airway obstruction.

• A client hospitalized with chronic dyspepsia is diagnosed with gastric

cancer. Which of the following is associated with an increased incidence of gastric cancer?

• Dairy products
• Carbonated beverages
• Refined sugars
• Luncheon meats

Answer D: Luncheon meats contain preservatives such as nitrites that have

been linked to gastric cancer. Answers A, B, and C have not been found to increase the risk of gastric cancer; therefore, they are incorrect.

• A client is sent to the psychiatric unit for forensic evaluation after he is

accused of arson. His tentative diagnosis is antisocial personality disorder. In

reviewing the client’s record, the nurse could expect to find:

• A history of consistent employment
• A below-average intelligence
• A history of cruelty to animals
• An expression of remorse for his actions

Answer C: A history of cruelty to people and animals, truancy, setting fires,

and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is incorrect because the client with antisocial personality disorder does not hold consistent employment. Answer B is incorrect because the IQ is usually higher than average. Answer D is incorrect because of a lack of guilt or remorse for wrong-doing.

6. The licensed vocational nurse may not assume the primary care for a client:

• In the fourth stage of labor
• Two days post-appendectomy
• With a venous access device
• With bipolar disorder

Answer C: The licensed vocational nurse may not assume primary care of the

client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disorder; therefore, answers A, B, and D are incorrect.

• The physician has ordered dressings with mafenide acetate (Sulfamylon)

cream for a client with full-thickness burns of the hands and arms. Before

dressing changes, the nurse should give priority to:

• Administering pain medication
• Checking the adequacy of urinary output
• Requesting a daily complete blood count
• Obtaining a blood glucose by finger stick

Answer A: Sulfamylon (mafenide acetate) produces a painful sensation when

applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Answers B, C, and D do not pertain to dressing changes for the client with burns, so they are incorrect.

• The nurse is teaching a group of parents about gross motor development

of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?

• She can pull a toy behind her.
• She can copy a horizontal line.
• She can build a tower of eight blocks. D. She can broad-jump.

Answer A: According to the Denver Developmental Screening Test, the

child can pull a toy behind her by age 2 years. Answers B, C, and D are not accomplished until ages 4–5 years; therefore, they are incorrect.

• A client hospitalized with a fractured mandible is to be discharged. Which

piece of equipment should be kept on the client with a fractured mandible?

• Wire cutters
• Oral airway
• Pliers
• Tracheostomy set

Answer A: The client with a fractured mandible should keep a pair of wire

cutters with him at all times to release the device in case of choking or aspiration. Answer B is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruction.

• The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with

a congenital heart defect. The nurse auscultates an apical pulse rate of 100.

The nurse should:

• Record the heart rate and call the physician
• Record the heart rate and administer the medication
• Administer the medication and recheck the heart rate in 15 minutes
• Hold the medication and recheck the heart rate in 30 minutes

Answer B: The infant’s apical heart rate is within the accepted range for

administering the medication. Answers A, C, and D are incorrect because the apical heart rate is suitable for giving the medication.

• A mother of a 3-year-old hospitalized with lead poisoning asks the nurse

to explain the treatment for her daughter. The nurse’s explanation is based on

the knowledge that lead poisoning is treated with:

• Gastric lavage
• Chelating agents
• Antiemetics
• Activated charcoal

Answer B: Chelating agents are used to treat the client with poisonings from

heavy metals such as lead and iron. Answers A and D are used to remove noncorrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; therefore, it is an incorrect response.