NCLEX Select All That Apply Practice Exam 6

Question 1

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Accepted Answer

Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.

Answer

Activity intolerance related to increased cardiac output.

Answer

Decreased cardiac output related to structural and functional changes.

Answer

Impaired gas exchange related to decreased sympathetic nervous system activity.

Question 2

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Accepted Answer

Verify patency of the line by the presence of a blood return at regular intervals.

Answer

Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.

Question 3

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Accepted Answer

Impulsiveness

Answer

Ritualistic behavior

Answer

Psychomotor retardation

Question 4

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

Accepted Answer

The client functions well in other areas of his life.

Answer

The violent behavior is most often justified by the stressor.

Answer

The client has no remorse about the inability to control his anger.

Question 5

Which of the following nursing interventions are written correctly? (Select all that apply.)

Accepted Answer

Elevate head of bed 30 degrees before meals.

Answer

Apply continuous passive motion machine during day.

Answer

Perform neurovascular checks.

Answer

Change dressing once a shift.

Question 6

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take.

Accepted Answer

Place the client in good body alignment

Answer

Contact the physician

Question 7

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

Accepted Answer

Excess Fluid Volume

Answer

Impaired Gas Exchange

Answer

Pain

Question 8

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

Accepted Answer

Head tilt

Answer

Polydipsia

Answer

Increased appetite

Answer

Increased pulse

Question 9

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Accepted Answer

Elevate the HOB to 90 degrees

Answer

Use a fan to reduce diaphoresis

Answer

Place the client in a supine position with legs elevated

Question 10

A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:

Accepted Answer

Low self-esteem

Answer

A religious experience

Answer

A stressful event

Answer

Overwhelming anxiety