NCLEX-RN : Procedures and Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #3 : Alcohol And Drug Abuse

A 42 year old man presents to the ER for alcohol toxicity. While taking the history, the nurse discovers that he drinks on average one fifth of vodka per night, and often must drink an additional 6-12oz to get "a good buzz." When he doesn't drink, he experiences tremors and feels unwell until he is able to drink again. When asked if he would like to quit drinking he states that he has tried unsuccessfully several times over his life. He knows that he needs to get control over his drinking because it is seriously impairing his relationship with his husband and their 13 year old daughter. 

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V), this patient can be considered to have which of the following conditions?

Possible Answers:

None of these

Substance dependency

Substance abuse

Substance addiction

Correct answer:

Substance dependency

Explanation:

The symptoms described by this patient put his alcohol use in the category of substance dependency, according to the DSM V, a more severe form of abuse than substance addiction. The criteria for this condition are:

  1. Tolerance 
  2. Withdrawal
  3. Unintentional excesses in consumption
  4. Persistent desire or unsuccessful efforts to reduce or control substance use
  5. A great deal of time is spent to get, use, or recover from the substance
  6. Interference with social life
  7. The substance use is continued despite knowledge problems caused by use

Example Question #1 : Alcohol And Drug Abuse

Prolonged alcohol abuse can result in a severe deficiency in what vitamin?

Possible Answers:

Niacin (B3)

Thiamine (B1)

Folate

Vitamin C

Correct answer:

Thiamine (B1)

Explanation:

Prolonged alcohol abuse can result in a severe deficiency in thiamine, or vitamin B1 by reducing dietary thiamine intake, impairing gastrointestinal absorption of thiamine, and causing impaired thiamine utilization in cells. Note that individuals who partake in prolonged alcohol abuse may have various other dietary deficiencies.

Example Question #1 : Alcohol And Drug Abuse

Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal?

Possible Answers:

Agitation

Tachycardia

Bradycardia

Delirium tremens

Correct answer:

Delirium tremens

Explanation:

Delirium tremens (DT) is a rapid onset of confusion seen during alcohol withdrawal. The symptoms of DT include altered mental status, autonomic instability, and even seizures. DT is also characterized by hallucinations such as the sensation of something "crawling" on the patient. DT is the most severe consequence of withdrawal and can be fatal if untreated.

Example Question #1 : Nurse Patient Relationship

The client in the termination phase of the nurse-client relationship is being very confrontational. How should the nurse interpret this behavior?
Possible Answers:
The nurse has done something to offend the client
This behavior is common for a client in the termination phase
The treatment should revisit the working phase
The patient should be admitted to the hospital
Correct answer: This behavior is common for a client in the termination phase
Explanation: Confrontational behavior is very common for a client in the termination phase. The nurse should not assume that she offended the client, and further action in terms of therapy should not be addressed until completing the termination phase.

Example Question #1 : Nurse Patient Relationship

The nurse is in the orientation phase of the nurse-client relationship where the client has been sexually assaulted. During this phase, the nurse should:
Possible Answers:
Establish acceptance, trust, and boundaries
Actively listen to the client express his thoughts and feelings
Identify themes of patterns of patient behavior and possible coping mechanisms
Explore personal ideas, stereotypes, and biases that my affect the nurse-client relationship
Correct answer: Establish acceptance, trust, and boundaries
Explanation: During the orientation phase the nurse should establish acceptance, trust, and boundaries with the client, which will be built upon in later phases.

Example Question #1 : Nurse Patient Relationship

Acceptance, trust and boundaries are established during which phase of the therapeutic nurse-client relationship?
Possible Answers:
Termination
Working
Orientation
Preinteraction
Correct answer: Orientation
Explanation: Acceptance, trust, and boundaries are established in the orientation phase of therapy.

Example Question #41 : Patient Specific Care

Identify the disorder that presents the following signs and symptoms: numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause.

Possible Answers:

Conversion disorder

Bipolar disorder

Schizophrenia

Stiff person syndrome

Correct answer:

Conversion disorder

Explanation:

Conversion disorder is typified by numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause. Schizophrenia, bipolar disorder, and stiff person syndrome all have medically identifiable causes. 

Example Question #42 : Patient Specific Care

What is the best approach towards dealing with a delirious patient?

Possible Answers:

Frequent reorientation to time, place, and name.

Frequent sedation with antipsychotics

Frequent sedation with benzodiazepenes

Frequent 4-point restraints

Correct answer:

Frequent reorientation to time, place, and name.

Explanation:

Delirium is an organic dysfunction of the brain usually seen in sick patients post-op. These patients need frequent reorientation to name, time, and place until the delirium resolves. Agitation, confusion, and difficult to control behavior is typically controlled with antipsychotics, however, they are not first line treatment. Restraints should be avoided at all costs.

Example Question #1 : Prevention And Risk Management

A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Possible Answers:
Tell the client to call back if the condition worsens
Ask the client if her daughter has ever been stung by a bee in the past
Advise the client to bring her daughter to the emergency room
Instruct the client to keep the arm elevated until swelling goes away
Correct answer: Tell the client to call back if the condition worsens
Explanation: The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.

Example Question #798 : Nclex

The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?

Possible Answers:

Teach client the importance of coughing and deep breathing

Use compression stockings or TED hose

Frequently turn and reposition patient while also providing skin care

Providing a well-balanced diet

Orient client frequently

Correct answer:

Frequently turn and reposition patient while also providing skin care

Explanation:

There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.

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