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

Heart failure results in the heart's inability to pump sufficient blood to meet the body's metabolic demands, leading to decreased cardiac output. This reduced pumping efficiency directly causes decreased blood flow to peripheral tissues, resulting in 'Ineffective tissue perfusion.' This diagnosis accurately reflects a major physiological consequence of heart failure.

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

When administering chemotherapy via a central venous line, verifying patency and inspecting the insertion site are critical safety measures. A blood return confirms the catheter is correctly positioned within the vein, preventing extravasation of vesicant drugs. If blood return is absent, repositioning the client or encouraging a cough may help, but if patency remains questionable, the healthcare provider must be contacted to verify placement before proceeding with administration.

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

Borderline Personality Disorder (BPD) is characterized by a pervasive pattern of instability in relationships, self-image, and emotions, along with marked impulsivity. Key features include impulsive behaviors (e.g., spending, substance abuse), rapid and intense shifts in mood (lability of mood), and self-destructive actions like self-mutilation or suicidal gestures. These symptoms contribute to the chaotic and unpredictable nature of the disorder.

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

Impulse control disorders, such as Intermittent Explosive Disorder, are characterized by recurrent aggressive outbursts that are grossly out of proportion to any provocation. Individuals often function well in other areas of their lives between episodes, but these outbursts are typically followed by distress, regret, or embarrassment. A history of parental alcoholism and chaotic, abusive family life are common risk factors contributing to the development of these disorders.

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

A correctly written nursing intervention should be specific, measurable, achievable, relevant, and time-bound (SMART). 'Elevate head of bed 30 degrees before meals' clearly specifies the action (elevate HOB), the degree (30 degrees), and the timing (before meals), making it a precise and actionable instruction. The other options lack sufficient detail regarding frequency, specific parameters, or timing.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Select All That Apply Practice Exam 6