Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 74

1. A client - s behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

A) Seclude him in his room.
B) Set limits on his behavior.
C) Have his medication increased.
D) Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

2. A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:

A) Insist that she remain at the table and eat a balanced diet.
B) Order a high-calorie diet with supplements.
C) Provide nutritious finger foods several times a day.
D) Offer to go to the dining room with her and allow her to open the food and inspect what she eats.

3. A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:

A) Doing crafts in occupational therapy
B) Working a 1000-piece puzzle
C) Playing bridge with three other clients
D) Playing basketball in the gym

4. A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

A) In the acutely depressed state
B) When the depression starts to lift
C) In the denial phase
D) During a manic episode

5. Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:

A) Relax muscles
B) Relieve anxiety
C) Reduce secretions
D) Act as an anesthetic

1. Right Answer: B
Explanation: (A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurses scope of practice. (D) This could be dangerous to the client and to others and violates other clients rights.

2. Right Answer: C
Explanation: (A) The client is not able to sit for long periods. Forcing her to remain at the table will increase her anxiety and cause her to become hostile. (B) This action will not ensure that the client eats what is ordered. Dietary orders are not within the nurses scope of practice. (C) Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run.' (D) These clients are not suspicious of the food or insecure in moving about the unit alone.

3. Right Answer: D
Explanation: (A) This activity requires motor skills and therefore would be difficult for a hyperactive client. (B) This activity would take too long, and the client would have difficulty concentrating owing to a limited attention span. (C) This client would not be able to concentrate enough to play card games. He would respond to all the stimuli in the area, become distracted, and leave the table. (D) This activity would allow the client to channel his energy in a positive way.

4. Right Answer: B
Explanation: (A) The client may be too disorganized in the acute phase to make a workable plan. (B) When the depression starts to lift, the client is able to make a workable plan. (C) There usually is not a significant denial phase related to depression. Suicide occurs in a state of despair and hopelessness. (D) Suicide is uncommon in the manic state. In this state, clients do not feel hopeless, but euphoric and overly confident.

5. Right Answer: A
Explanation: (A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.

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