NCLEX Select All That Apply Practice Exam 11
A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply:
Please select 3 correct answers
Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.
Select all that apply to the use of barbiturates in treating insomnia:
Please select 3 correct answers
Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.
Select all that apply that is appropriate when there is a benzodiazepine overdose:
Please select 3 correct answers
If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.
A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.
Please select 2 correct answers
The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.
Please select 4 correct answers
Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.
Please select 4 correct answers
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.
Please select 3 correct answers
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.
Please select 3 correct answers
Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.
Which data indicates to the nurse that a client may be experiencing ineffective coping?
Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.
The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
Children with cystic fibrosis are susceptible to chronic sinusitis and nasal polyps, which might require surgical removal. Answer A is incorrect because it is a congenital condition in which there is a bony obstruction between the nares and the pharynx. Answers C and D are not specific to the child with cystic fibrosis; therefore, they are incorrect.
A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?
Lipid-lowering agents are contraindicated in the client with active liver disease. Answers A, B, and C are incorrect because they are not contraindicated in the client with active liver disease.
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
Oatmeal is low in sodium and high in fiber. Limiting sodium intake and increasing fiber helps to lower cholesterol levels, which reduce blood pressure. Answer A is incorrect because cornflakes and whole milk are higher in sodium and are poor sources of fiber. Answers B and D are incorrect because they contain animal proteins that are high in both cholesterol and sodium.
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
The child will need to avoid straddle toys, swimming, and rough play until allowed by the surgeon. Answers B, C, and D do not relate to the post-operative care of the child with hypospadias; therefore, they are incorrect.
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
Eating a carbohydrate source such as dry crackers or toast before arising helps alleviate symptoms of morning sickness. Answer B is incorrect because the additional fat might increase the client’s nausea. Answer C is incorrect because the client does not need to skip meals. Answer D is the treatment of hypoglycemia, not morning sickness; therefore, it is incorrect.
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
The stethoscope should be left in the client’s room for future use. The stethoscope should not be returned to the exam room or the nurse’s station; therefore, answers B and D are incorrect. The stethoscope should not be used to assess other clients; therefore, answer C is incorrect.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:
The medication will be needed throughout the child’s lifetime. Answers A, C, and D contain inaccurate statements; therefore, they are incorrect.
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