NCLEX PN Review 21-30

Passing the NCLEX PN Review is a step toward a fulfilling career in the field of nursing.

21. The 57-year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would:

A. Place him in the Trendelenburg position
B. Obtain an order for Benedryl
C. Administer oxygen per nasal cannula
D. Speed the IV infusion of normal saline

22. A client has cancer of the pancreas. The nurse should be most concerned with which nursing diagnosis?

A. Alteration in nutrition
B. Alteration in bowel elimination
C. Alteration in skin integrity
D. Ineffective individual coping

23. NCLEX PN Review about the nurse who is caring for a client with ascites. Which is the best method to use for determining early ascites?

A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave

24. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception

25. Which information obtained from the visit to a client with hemophilia would cause the most concern? The client:

A. Likes to play football
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell tract
D. Is taking acetaminophen to control pain

26. NCLEX PN Review about the nurse on oncology who is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?

A. Ask the visitor to wash his hands
B. Document the visitor’s condition in the chart
C. Ask the visitor to leave and not return until the client’s white blood cell count is 1,000
D. Provide the visitor with a mask and gown

27. The nurse is caring for the client admitted after trauma to the neck in an automobile accident. The client suddenly becomes unresponsive and pale, with a BP of 60 systolic. The initial nurse’s action should be to:

A. Place the client in Trendelenburg position
B. Increase the infusion of normal saline
C. Administer atropine IM
D. Obtain a crash cart

28. Immediately following the removal of a chest tube, the nurse would:

A. Order a chest x-ray
B. Take the blood pressure
C. Cover the insertion site with a Vaseline gauze
D. Ask the client to perform the Valsalva maneuver

29. A client being treated with sodium warfarin has an INR of 9.0. Which intervention would be most important to include in the nursing care plan?

A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments

30. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?

A. A glass of orange juice
B. A blueberry muffin
C. A cup of yogurt
D. A banana

NCLEX PN Review Answers

21) D
- If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn him to the left side if possible, apply oxygen by mask, and speed the IV infusion. Epinephrine, not Benedryl, in answer B, should be kept for emergency administration. A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down, ventilating the client. Answer C is incorrect because the oxygen should be applied by mask, not cannula.

22) A
- Cancer of the pancreas frequently leads to severe nausea and vomiting. Answers B, C, and D are incorrect because although they are a concern to the client, they are not the priority nursing diagnosis.

23) C
- NCLEX PN Review Rationale: Measuring the girth daily with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspection, in answer A, and checking for fluid waves, in answer D, are more subjective and not correct. Palpation of the liver will not tell the amount of ascites, so answer B is incorrect.

24) B
- The vital signs indicate hypovolemic shock, so checking for fluid volume deficit is the appropriate action. Answers A, C, and D do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, and are incorrect.

25) A
- The client with hemophilia is likely to experience bleeding episodes if he participates in contact sports. Drinking several carbonated drinks per day, as in answer B, has no bearing on the hemophiliac’s condition. Having two sisters with sickle cell, as in answer C, is not information that would cause concern. Taking acetaminophen for pain, as in answer D, is an accepted practice and does not cause concern.

26) D
- NCLEX PN Review Rationale: The client with neutropenia should not have visitors with any type of infection, so the best action by the nurse is to give the visitor a mask and a gown. Asking the visitor to wash his hands is good but will not help prevent the infection from spreading by droplets; therefore, answer A is incorrect. Answer B is incorrect because documenting the visitor’s condition is not enough action for the nurse to take. Answer C is incorrect because asking the visitor to leave and not return until the client’s white blood cell count is 1,000 is an insuffient intervention. The normal WBC is 5,000–10,000, so a WBC of 1,000 is not high enough to prevent the client from contracting infections.

27) B
- For some clients with trauma to the neck, the answer would be A; however, in this situation, it is incorrect because lowering the head of the bed could further interfere with the airway. Increasing the infusion and placing the client in supine position is better. If atropine is administered to the client, it should be given IV, not IM, and there is no need for this action at present, as stated in answer C. Answer D is not necessary at this time.

28) C
- When a chest tube is removed, the hole should be immediately covered with a Vaseline gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not the nurse, will order a chest x-ray; therefore, answer A is incorrect. Taking the BP in answer B is good but is not the priority action. Answer D is incorrect because the Valsalva maneuver is done during removal of the tube, not afterward.

29) A
- The normal international normalizing ratio (INR) is 2–3. A 9 might indicate spontaneous bleeding. Answer B is an incorrect action at this time. Answer C is incorrect because just instructing the client regarding his medication is not enough. Answer D is incorrect because increasing the frequency of neurological assessment will not prevent bleeding caused by the prolonged INR.

30) C
- The food with the most calcium is the yogurt. The others are good choices, but not as good as the yogurt, which has approximately 400mg of calcium. Therefore, answers A, B, and D are incorrect.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX PN Review 1-10

Or proceed to the next set of questions:

NCLEX PN Review 31-40

NCLEX PN Practice Questions 11-20

Read each NCLEX PN Practice Questions carefully and choose the best answer.

11. The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?

A. Hematocrit
B. Creatinine
C. White blood cell count
D. Erythrocyte count

12. The nurse is caring for the client with a mastectomy. Which action would be contraindicated?

A. Taking the blood pressure in the side of the mastectomy
B. Elevating the arm on the side of the mastectomy
C. Positioning the client on the unaffected side
D. Performing a dextrostix on the unaffected side

13. NCLEX PN Practice Questions about the charge nurse who is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take?

A. Change the nurse’s assignment to another client
B. Explain to the nurse that there is no risk to the client
C. Ask the nurse if the chickenpox have scabbed
D. Ask the nurse if she has ever had the chickenpox

14. The client with brain cancer refuses to care for herself. Which action by the nurse would be best?

A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client
B. Talk to the client and explain the need for self-care
C. Explore the reason for the lack of motivation seen in the client
D. Talk to the doctor about the client’s lack of motivation

15. The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

A. Contact organ retrieval to come talk to the wife
B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband
C. Drop the subject until a later time
D. Refrain from talking about the subject until after the death of her husband

16. NCLEX PN Practice Questions about the nurse who is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:

A. Inspection, auscultation, palpation
B. Auscultation, palpation, inspection
C. Palpation, inspection, auscultation
D. Inspection, palpation, auscultation

17. The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking?

A. Interactions between medications can be identified.
B. Various medications taken by mouth can affect the alimentary tract.
C. This will provide an opportunity to educate the patient regarding the medications used.
D. The types of medications might be attributable to an abdominal pathology not already identified.

18. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following:

A. “Peptic ulcers result from overeating fatty foods.”
B. “Peptic ulcers are always caused from exposure to continual stress.”
C. “Peptic ulcers are like all other ulcers, which all result from stress.”
D. “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.”

19. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?

A. Anxiety
B. Pain
C. Knowledge deficit
D. Altered thought process

20. The nurse understands that the diagnosis of oral cancer is confirmed with:
A. Biopsy
B. Gram Stain
C. Scrape cytology
D. Oral washings for cytology

Answers to NCLEX PN Practice Questions

11) B
- Gentamycin is a drug from the aminoglycocide classification. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant

12) A
- The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side.

13) D
- NCLEX PN Practice Questions Rationale: The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary.Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present.

14) C
- The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary.

15) A
- Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect.

16) A
- NCLEX PN Practice Questions Rationale: The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the assessment might be unreliable. Therefore, answers B, C, and D are incorrect.

17) B
- Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect.

18) D
- H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress.

19) C
- The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect.

20) A
- The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX PN Practice Questions 1-10

Or proceed to the next set of questions:

NCLEX PN Practice Questions 21-30

NCLEX PN Practice Questions 1-10

Are you looking for NCLEX PN Practice Questions? We are here to help!

1. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:

A. Document the finding
B. Send a specimen to the lab
C. Strain the urine
D. Obtain a complete blood count

2. NCLEX PN Practice Questions about the client with cirrhosis of the liver who is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:

A. To lower the blood glucose level
B. To lower the uric acid level
C. To lower the ammonia level
D. To lower the creatinine level

3. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?

A. “I live by myself.”
B. “I have trouble seeing.”
C. “I have a cat in the house with me.”
D. “I usually drive myself to the doctor.”

4. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?

A. Hemoglobin
B. Creatinine
C. Blood glucose
D. White blood cell count

5. NCLEX PN Practice Questions about the client with a myocardial infarction who comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

A. Rationalization
B. Denial
C. Projection
D. Conversion reaction

6. Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?

B. Troponin
D. Myoglobin

7. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
B. A gravida I para 1 that is Rh negative with an Rh-positive baby
C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
D. A gravida IV para 2 that is Rh negative with an Rh-negative baby

8. NCLEX PN Practice Questions about the first exercise that should be performed by the client who had a mastectomy is:

A. Walking the hand up the wall
B. Sweeping the floor
C. Combing her hair
D. Squeezing a ball

9. The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?

A. Atropine sulfate
B. Furosemide
C. Prostigmin
D. Promethazine

10. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?

A. “You will need to lay flat during the exam.”
B. “You need to empty your bladder before the procedure.”
C. “You will be asleep during the procedure.”
D. “The doctor will inject a medication to treat your illness during the procedure.”

Answers of NCLEX PN Practice Questions

1) B
- If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.

2) C
- Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values.

3) B
- NCLEX PN Practice Questions Rationale: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.

4) C
- When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.

5) B
- The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect.

6) A
-  NCLEX PN Practice Questions Rationale: Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.

7) D
- The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. The mother in answer D is the only one who does not require a RhoGam injection.

8) D
- The first exercise that should be done by the client with a mastectomy is squeezing the ball. Answers A, B, and C are incorrect as the first step; they are implemented later.

9) A
- NCLEX PN Practice Questions Rationale: Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect.

10) B
- The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances).

Proceed to the next set of questions:

NCLEX PN Practice Questions 11-20

Anxiety Disorder NCLEX Questions 11-20

The following are anxiety disorder NCLEX questions

Situation: F. the nurse-manager in the cardiac clinic, notes that many patients seem confused and overwhelmed by the number of medications prescribed for their heart conditions. She suggests implementing medication management groups. The idea is well received by the treatment team. Anxiety Disorder NCLEX Questions are:

11. F. should begin planning for the groups by carefully assessing:

a) the nature of the problems that patients are having with their medications
b) which patients would be interested in joining such a group
c) which staff members are prepared to be leaders or co-leaders of the groups
d) the best time of day to offer such groups

12. F. consults the hospital's clinical nurse specialist in psychiatric nursing about group size. The nurse specialist will most likely say that the optimal number of patients in each group is:

a) 5
b) 10
c) 20
d) unlimited

13. The nurse specialist recommends forming three medication management groups with F. as leader and another nurse as co-leader. Each group meets once a week for 30 minutes in 4 week cycles. What is the best approach to establishing membership in each group?

a) require all cardiac clinic patients to attend
b) assign patients to groups that are offered on their clinic visit days
c) permit patients to join any group or attend any session
d) screen patients, and explain the group's goals and purposes to them

14. Anxiety Disorder NCLEX Questions: F. and her co-leader plan to meet weekly with the clinical nurse specialist for supervision and review of group progress. To facilitate these sessions, the nurse specialist should:

a) ask the leader and co-leader to keep a log or journal of each group session
b) review each group member's chart weekly
c) ask the patients how they feel about the group and its progress
d) meet with the leader and co-leader separately for supervision

15. During the group sessions, F. identifies several patients who demonstrate anxiety, ineffective coping, and hopelessness related to the impact of adjusting to serious cardiac illness. The most beneficial form of group therapy for these patients is likely to be led by:

a) F. and another nurse
b) a psychiatric clinical nurse specialist
c) a cardiology resident
d) other cardiac patients who have coped successfully with similar problems

Anxiety Disorder NCLEX Questions Situation: T., a 44 year old married woman with one son, was referred to the mental health clinic by her family physician after he ruled out any physical basis for her complaints of insomnia, anxiety, fatigue, and loss of interest in her usual activities. On arrival at the clinic, T. sates that her symptoms have increased over the last few weeks to the point that she feels "too tired" most of the time to take care o her home or leave the house.

16. During the initial assessment, the nurse suspects that T. may be having a situational crisis. Which question is most effective in beginning to explore this possibility?

a) what has changed in your life recently?
b) do you think your symptoms are related to a recent event in your life
c) what do you think is causing your symptoms
d) tell me all about yourself

17. T. relates that her father died 7 years ago and that her mother is extremely lonely and misses her father very much. While listening to T., the nurse should further assess for:

a) the patient's feelings about her mother
b) the patient's feelings about her father
c) any recent losses in the patient's life
d) the patient's relationships with relatives and friends

18. Anxiety Disorder NCLEX Questions: During the assessment interview, T. reveals that her only son moved to another state 2 months ago and that her husband has been traveling frequently on business lately. The nurse inquires about the patient's close relatives and friends. These inquiries should be directed at:

a) encouraging the patient to form closer relationships with others to replace those with her son and husband
b) identifying the patient's available support systems
c) helping the patient to realize she is not alone
d) helping the patient to develop new coping mechanisms

19. The treatment team determines that T. is in a situational crisis. Which nursing diagnostic category is most applicable at this time?

a) dysfunctional grieving
b) altered thought processes
c) adjustment disorder
d) ineffective individual coping

20. All of the following therapeutic approaches are appropriate for counseling T. except:

a) ventilation
b) clarification
c) support of defense
d) interpretation

Anxiety Disorder NCLEX Questions

11) A
- when planning groups, the nurse must begin by assessing the patient's needs and resources. Ascertaining the nature of the patient's medication problem is crucial. Once this is accomplished, the nurse can select the leaders and co-leaders who are best able to meet the identified patient needs. Establishing the level of patient interest in a group and determining the best time to meet are part of later planning.

12) B
- Anxiety Disorder NCLEX Questions Rationale: although there is no hard and fast agreement, 10 patients usually is considered an ideal size for therapeutic group. A group of this size permits opportunities for maximum therapeutic exchange and participation. With 5 or fewer members, participation often is inhibited by self-consciousness. In groups or more than 15 members, overall participation may be inhibited by the formation of smaller patient subgroups. Permitting an unlimited number of members in a group is unwise. Part of the therapeutic benefit is lost if there is no consistency of membership or if the group becomes too large to permit therapeutic interaction.

13) D
- group leaders should meet before the group sessions to screen and orient prospective members. At this time, the leader can determine a patient's appropriateness for the group -- for example, a patient with a serious hearing problem may benefit more from an individual approach. The screening period also provides the leaders with an opportunity to explain the purpose and goals of the group and to clarify patient expectations. Requiring or assigning patients to groups limits their participation in treatment planning and may result in inappropriate group membership that could be non-therapeutic for other patients. Because consistent group membership encourages attainment of the therapeutic goals, planned patient selection is important.

14) A
- Anxiety Disorder NCLEX Questions Rationale: using a log or journal to follow and review group progress is an important supervisory aid. The log should document group themes, individual patient responses. and interventions and their effect. The co-leader can keep the log during the group meeting or write it as soon as possible after the session ends. The leaders and supervisor can use the log to review group progress and to analyze interventions and strategies. (Other effective methods of tracking group sessions include audiotaping, audiovisual recording, and inviting outsiders to record their observations; however, these methods usually require the patient's consent.) Although patient's records and interviews are useful part of the group's overall evaluation and effectiveness, they are not helpful in reviewing group progress during supervisory sessions; supervisory sessions should focus on the group leaders and their feelings about the progress of sessions. Having the leader and co-leader attend supervisory sessions together allows them to discuss their perceptions of events and enables the supervisor to pursue conflicting statements while the leaders are together.

15) B
- the psychiatric clinical nurse specialist is an appropriate leader for group therapy with cardiac patients who demonstrate anxiety, ineffective individual coping, and hopelessness. A psychiatric clinical nurse specialist with a master's degree who has been supervised in group therapy has the knowledge and experience necessary for this level of nursing intervention. F., as nurse-manager, might be asked to participate as a co-leader but does not have the expertise to lead on her own. A cardiology resident has expertise in medical management but not in group therapy. After the patients have been assisted to develop more effective coping skills, a self-help group composed of other cardiac patients is a means of maintaining these skills.

16) A
- Anxiety Disorder NCLEX Questions Rationale: crisis intervention focuses on identifying and solving the patient's immediate presenting problem. By asking about recent changes in the patient's life, the nurse tries to identify factors related to the problem. It is too early in the therapeutic relationship to ask the patient to link her present symptoms to recent life changes. Such analysis needs further exploration and should be based on trust established in the nurse-patient relationship. Because the patient is seeking an answer to her problem, asking her to identify what is causing the symptoms is not helpful. Complete diagnostic assessments typically include extensive explorations of the past and are not done in crisis intervention.

17) C
- identifying underlying themes is an important part of the assessment process in crisis intervention. In this situation, the nurse identifies a theme of loss or abandonment and seeks further clues to recent losses that may have activated the patient's anxiety. The patient's feelings about her mother and father are less important than recent events and her response to them. Once the stressors and the patient's needs are identified, the nurse can assist the patient in identifying positive relationships with friends and relatives.

18) B
- Anxiety Disorder NCLEX Questions Rationale: during a crisis, a patient typically has difficulty dealing realistically with events, plans, and decisions. Identifying available support networks is an essential part of crisis intervention. The nurse tries to foster adaptive coping and encourage the use of available support systems to help the patient reestablish equilibrium. The nurse should never imply that relationships are replaceable, which belittles the patient's feelings. The nurse may find that the patient has no readily available support system. In this case, the nurse should direct the patient to a crisis group that can provide the needed support. Developing new coping mechanisms is not a primary goal of crisis intervention, which focuses on short-term solutions and is directed toward supporting previous healthy coping mechanisms. Some patients, however, do develop new coping mechanisms in times of crisis.

19) D
- Anxiety Disorder NCLEX Questions Rationale: the most appropriate nursing diagnostic category for T. is Ineffective individual coping. In a crisis, a patient's coping skills are compromised or overwhelmed and become ineffective; equilibrium is typically upset by external events, such as T.'s son moving away and her husband's increased travel. Because the onset of symptoms is clearly related to these events and not to her father's death, the nursing diagnostic category of Dysfunctional grieving is unsupported. No evidence supports the diagnostic category of Altered thought processes, and Adjustment disorder is a medical diagnosis, not a nursing diagnostic category.

20) D
- the therapeutic technique of interpretation rarely is used in crisis counseling. Interpretation, which is directed at helping a patient link unconscious factors with present behaviors, is more appropriate in long-term therapy. Ventilation encourages the patient to talk about pent-up feelings to relieve tension. Clarification, a process of verbalizing relationships between events, helps the patient link events in a crisis and understand their relationship; if the patient cannot see the relationships, the nurse may need to point them out. Crisis intervention seeks to support healthy, adaptive defenses rather than develop new ones.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Anxiety Disorder NCLEX Questions 1-10

Or proceed to the next set of questions:

Anxiety Disorder NCLEX Questions 21-30

Depression NCLEX Questions 1-10

Accomplish this 5-item Depression NCLEX Questions and do good in your NCLEX!

1. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?

a) Ask the client why he started taking illegal drugs.
b) Ask the client about the amount of drug use and its effect.
c) Ask the client how long he thought that he could take drugs without someone finding out.
d) Not ask any questions for fear that the client is in denial and will throw the nurse out of the home. 

2. Depression NCLEX Questions about which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

a) Monitor vital signs.
b) Maintain NPO status.
c) Provide a safe environment.
d) Address hallucinations therapeutically.
e) Provide stimulation in the environment.
f) Provide reality orientation as appropriate.

3. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?

a) “I no longer feel that I deserve the beatings my husband inflicts on me.”
b) “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
c) “I enjoy attending the meetings because they get me out of the house and away from my husband.” d) “I can tolerate my husband’s destructive behaviors now that I know they are common with alcoholics.”

4. Depression NCLEX Questions about a hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want any more treatment. I have things that I have to do right away.” The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?

a) Call the nursing supervisor.
b) Call security to block all exit areas.
c) Restrain the client until the health care provider (HCP) can be reached.
d) Tell the client that the client cannot return to this hospital again if the client leaves now.

5. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply.

a) Dental decay
b) Moist oily skin
c) Loss of tooth enamel
d) Electrolyte imbalances
e) Body weight well below ideal range

6. Depression NCLEX Questions about which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

a) The adolescent gives away a DVD and a cherished autographed picture of a performer.
b) The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room.
c) The adolescent becomes angry while speaking on the telephone and slams down the receiver.
d) The adolescent gets angry with her roommate when the roommate borrows the client’s clothes without asking.

7. The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action?

a) Administer an antianxiety agent.
b) Examine and treat the wound sites.
c) Secure and record a detailed history.
d) Encourage and assist the client to ventilate feelings.

8. Depression NCLEX Questions about a moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” How should the nurse interpret this behavior as a cue to modify the treatment plan?

a) Suggesting a reduction of medication
b) Allowing increased “in-room” activities
c) Increasing the level of suicide precautions
d) Allowing the client off-unit privileges as needed

9. Low doses of central nervous system (CNS) depressants produce an initial excitatory response. This reaction is caused by:

a) a stimulating effect on the CNS
b) the depression of acetylcholine
c) the stimulation of dopamine by depressant drugs
d) inhibitory synapses in the brain being depressed before excitatory synapses.

10. A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy - namely, the nurse the client is talking to at the time. This client is demonstrating which behavior?

a) confidentially
b) splitting
c) empathy
d) gnawing

Depression NCLEX Questions
Answers and Rationale

1) B
- Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option A is incorrect because it is judgmental and off-focus, and reflects the nurse’s bias. Option C is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option D is incorrect because it indicates passivity on the nurse’s part and uses rationalization to avoid the therapeutic nursing intervention.

- Depression NCLEX Questions Test-Taking Strategy: Focus on the subject, providing appropriate nursing care. Use of therapeutic communication techniques will assist in directing you to the correct option. 

2) A, C, D, F
- Depression NCLEX Questions Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

- Test-Taking Strategy: Note the strategic words most appropriate. Use therapeutic communication techniques to assist in selecting the correct interventions. Also, recalling the characteristics associated with alcohol withdrawal will assist in answering correctly.

3) A
- Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option B is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option C indicates that the group is viewed as an escape, not as a place to work on issues. Option D indicates that the wife remains codependent.

- Depression NCLEX Questions Test-Taking Strategy: Focus on the subject, the therapeutic effect of attending an Al-Anon group. Noting the words benefiting from attending an Al-Anon group will direct you to the correct option.

4) A
- Rationale: Most health care facilities have documents that the client is asked to sign relating to the client’s responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the “against medical advice” document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client’s will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

- Test-Taking Strategy: Keeping the concept of false imprisonment in mind, eliminate options B and C because they are comparable or alike. Eliminate option D, knowing that all clients have a right to health care. From the options presented, the best action is presented in the correct option.

5) A, C, D
- Depression NCLEX Questions Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

- Test-Taking Strategy: Focus on the subject, assessment findings in bulimia nervosa. It is necessary to recall that in anorexia nervosa the body weight is normally well below ideal body weight and that clients with bulimia nervosa are often at or slightly below ideal body weight. Also, remember that skin texture will be dry and scaly.

6) A
- Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options B, C, and D deal with anger and acting-out behaviors that are often typical of any adolescent.

- Test-Taking Strategy: Eliminate options B, C, and D because they are comparable or alike. The correct option is different and is an action that could indicate that the client may be “saying goodbye.”

7) B
- Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options A, C, and D, may follow after the client has been treated medically.

- Test-Taking Strategy: Note the strategic word initial. Use Maslow’s Hierarchy of Needs theory to prioritize. Physiological needs come first. The correct option addresses the physiological need.

8) C
- Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

Depression NCLEX Questions Test-Taking Strategy: Focus on the subject, suicide precautions. Options A and D support the client’s notion that a cure has occurred. Option B allows the client to increase self-isolation self-isolation and would present a threat to the client’s safety. Knowing that safety is of the utmost importance will direct you to the correct option.

9) D
- Excitation can occur when inhibitory synapses are depressed. The other options are incorrect because depressants don't stimulate the CNS or dopamine and don't depress acetylcholine.

10) B
- In splitting, or primitive dissociation, the client categorizes people as good or bad and tries to keep the bad from contaminating the good. Such a client may view a staff member is ideal and then devalue that person. Confidentially is the protection of client information. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. Gnawing isn't a term used in psychiatric nursing.

Proceed to the next set of questions:

Depression NCLEX Questions 11-20

RN Comprehensive Online Practice (NCLEX 6-10)

Nurses who will be taking the NCLEX exam should take our RN Comprehensive Online Practice quizzes. These free questions will help you enhance your critical thinking skills and make you more prepared for the actual exam. 
6. The nurse is preparing a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?
a) Urinary incontinence
b) Signs of skin breakdown
c) The presence of bowel sounds
d) Signs of infection around the pin sites

7. RN Comprehensive Online Practice question about the home care nurse who is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client?

a) The need for sensory stimulation
b) The amount of home care support available
c) The ability to perform activities of daily living
d) The type of transportation available for follow-up care

8. What action should the nurse consider when counseling a client of the Amish tradition?

a) Speak only to the husband.
b) Use complex medical terminology.
c) Avoid using scientific or medical jargon.
d) Stand close to the client and speak loudly.

9. A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client had been losing weight for the previous 2 months. The nurse enters the room, looks at the tray, and states, “If you don’t eat any more than that, I’m going to have to put a tube down your throat and get a feeding in that way.” The client begins crying and tries to eat more. Based on the nurse’s actions, the nurse may be accused of which violation?

a) Assault
b) Battery
c) Slander
d) Invasion of privacy

10. When making assignments to a team consisting of a registered nurse (RN), one licensed practical nurse (LPN), and two unlicensed assistive personnel (UAP), which is the best client for the LPN?

a) A client requiring frequent temperature checks
b) A client requiring assistance with ambulation every 4 hours
c) A client on a mechanical ventilator requiring frequent assessment and suctioning
d) A client with a spinal cord injury requiring urinary catheterization every 6 hours as prescribed

RN Comprehensive Online Practice
Answers and Rationale

6) B
- Rationale: Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client’s skin. Traction is maintained with 5 to 8 lb of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

- RN Comprehensive Online Practice Test-Taking Strategy: Note the strategic word priority. Eliminate option D first because there are no pin sites with skin traction. Visualizing the traction setup and knowledge of the complications associated with this type of traction will direct you to the correct option.

7) A
- Rationale: A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

- Test-Taking Strategy: Focus on the strategic words most appropriate and note the subject, psychosocial adjustment. Option C can be eliminated first because it relates to physiological integrity rather than psychosocial integrity. Next, eliminate options B and D because they are most closely related to physical supports, rather than psychosocial needs of the client.

8) C
- Rationale: Complex scientific or medical terminology should be avoided when counseling an Amish client (or any client). When counseling a female Amish client, most often the husband and wife will want to discuss health care options together. Standing close and speaking loudly is inappropriate in most counseling situations.

- RN Comprehensive Online Practice Test-Taking Strategy: Use knowledge of the Amish society and therapeutic communication techniques to answer this question. Options B and D can be eliminated first because option D is inappropriate and option B is not a therapeutic intervention. In addition, note that options B and C are opposite, which may indicate that one of these options is correct. Option A can be eliminated because of Amish cultural habits.

9) A
- Rationale: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another’s body without the person’s consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client’s personal affairs or violates confidentiality.

- Test-Taking Strategy: Note the subject, legal implications for nursing care. Focusing on the words used by the nurse and noting that the nurse threatens the client will direct you to the correct option.

10) D
- Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the UAP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option D would be assigned to this staff member.

- Test-Taking Strategy: Focus on the subject, the principles related to delegations and assignments, and consider the education and job position as described by the nurse practice act and employee guidelines. Note the word assessment in option C. This should alert you that this client should be assigned to the registered nurse. Options A and B can be eliminated because a UAP can perform these tasks.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

RN Comprehensive Online Practice (NCLEX 1-5)

Or proceed to the next set of questions:

RN Comprehensive Online Practice (NCLEX 11-15)

RN Comprehensive Online Practice (NCLEX 1-5)

Nurses who will be taking the NCLEX exam should take our RN Comprehensive Online Practice quizzes. These free questions will help you enhance your critical thinking skills and make you more prepared for the actual exam.1. The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position that could aggravate breathing?
a) Sitting up and leaning on a table
b) Standing and leaning against a wall
c) Sitting up with the elbows resting on knees
d) Lying on the back in a low-Fowler’s position

2. RN Comprehensive Online Practice question about a client who is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

a) Side-lying with a pillow under the hip
b) Prone with a pillow under the abdomen
c) Prone in slight Trendelenburg’s position
d) Side-lying with the legs pulled up and the head bent down onto the chest

3. The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family?

a) The nurse encourages the client and family to identify and discuss feelings openly.
b) The nurse assists the client and family in carrying out spiritually meaningful practices.
c) The nurse makes decisions for the client and family to relieve them of unnecessary demands.
d) The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

4. RN Comprehensive Online Practice question about a depressed client who verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure. I can’t do anything right.” How should the nurse plan on responding to the client’s statement?

a) Reassure the client that things will get better.
b) Tell the client that this is not true and that we all have a purpose in life.
c) Identify recent behaviors or accomplishments that demonstrate the client’s skills.
d) Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

5. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 

a) Head midline
b) Neck in neutral position
c) Head of bed elevated 30 to 45 degrees
d) Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

RN Comprehensive Online Practice
Answers and Rationale

1) D
- Rationale: The client should use the positions outlined in options A, B, and C. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client’s chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

- Test-Taking Strategy: Focus on the subject, the positions to avoid that could aggravate breathing. Also, note that options A, B, and C are comparable or alike in that they all address upright positions.

2) D
- Rationale: A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

- RN Comprehensive Online Practice Test-Taking Strategy: Focus on the subject, lumbar puncture. Recalling that a lumbar puncture is the introduction of a needle into the subarachnoid space will direct you to the correct option. It is reasonable that the position of the client must facilitate this, and the correct option is the only position that flexes the vertebrae and widens the spaces between them.

3) C
- Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option A describes encouraging discussion of feelings and is likely to enhance communications. Option B is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option D is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The correct option describes the nurse removing autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could impair communication further.

- RN Comprehensive Online Practice Test-Taking Strategy: Focus on the subject, the intervention that is unlikely to facilitate effective communication. Use of therapeutic communication techniques and focusing on the subject will assist in answering correctly. Also, understanding that people in crisis usually feel helpless and unable to control their circumstances can assist in identifying the correct option as a response that further removes control.

4) C
- Rationale: Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted cognitive view of self. Options A and B give advice and devalue the client’s feelings. Silence may be interpreted as agreement.

- RN Comprehensive Online Practice Test-Taking Strategy: Use therapeutic communication techniques and focus on the client’s diagnosis. You can eliminate options A and B easily because they are nontherapeutic. From the remaining options, focusing on the client’s diagnosis will direct you to the correct option.

5) A, B, C
- Rationale: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.

- Test-Taking Strategy: Focus on the subject, care of the client with increased intracranial pressure. Visualize each of the positions identified in the options and identify those that will promote venous drainage from the cranium.

Proceed to the next set of questions:

RN Comprehensive Online Practice 6-10