Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 40

1. Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the clients depression alert the nurse to prioritize problems and care by addressing which of the following problems first:

A) Nutritional status
B) Impaired thinking
C) Possible harm to self
D) Rest and activity impairment

2. The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:

A) Hypertensive crisis
B) Severe rash
C) Severe hypotension
D) Severe diarrhea

3. A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

A) Impaired communication
B) Sensory-perceptual alterations
C) Altered thought processes
D) Impaired social interaction

4. A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:

A) Ideas of reference
B) Delusions of persecution
C) Thought broadcasting
D) Delusions of grandeur

5. A client experiencing delusions states, 'I came here because there were people surrounding my house that wanted to take me away and use my body for science.' The best response by the nurse would be:

A) 'Describe the people surrounding your house that want to take you away.'
B) 'I need more information on why you think others want to use your body for science.'
C) 'There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.'
D) 'I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.'

1. Right Answer: C
Explanation: (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine clients sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.

2. Right Answer: A
Explanation: (A) The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. (B) MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. (C) MAO inhibits false neurotransmitters (phenylalanines) and may produce hypotensive reactions from gradual accumulation of these neurotransmitters. (D) The most serious adverse reactions of MAO inhibitors involve blood pressure.

3. Right Answer: B
Explanation: (A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions.

4. Right Answer: D
Explanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.

5. Right Answer: D
Explanation: (A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the clients delusional system may force the client to defend it, and you cannot change the delusion through logic.(D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.

80% DISCOUNT: NCLEX-RN PRACTICE EXAMS