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Home Test Prep NCLEX-RN

Test Prep NCLEX-RN Exam Practice Questions (P. 4)

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Question #31
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
  1. A
    Maintaining seizure precautions
  2. B
    Restricting fluid intake
  3. C
    Increasing sensory stimuli
  4. D
    Applying ankle and wrist restraints

Correct Answer:
A
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C)
Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.

Question #32
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
  1. A
    Somatic
  2. B
    Grandiose
  3. C
    Persecutory
  4. D
    Nihilistic B

Correct Answer:
Explanation
(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence.

Question #33
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
  1. A
    Auditory
  2. B
    Gustatory
  3. C
    Olfactory
  4. D
    Visceral

Correct Answer:
B
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.

Question #34
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?
  1. A
    Displacement
  2. B
    Projection
  3. C
    Reaction formation
  4. D
    Suppression B

Correct Answer:
Explanation
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing ones thoughts or feelings to another person. (C)
Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.

Question #35
Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:
  1. A
    Kidney (urinary system)
  2. B
    Brain (nervous system)
  3. C
    Heart (circulatory system)
  4. D
    Lungs (respiratory system)

Correct Answer:
B
(A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 minutes of water submersion.
(C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion.

Question #36
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
  1. A
    Peripheral circulatory collapse
  2. B
    Syndrome of inappropriate antiduretic hormone
  3. C
    Cerebral edema resulting in hydrocephalus
  4. D
    Auditory nerve damage resulting in permanent hearing loss A

Correct Answer:
Explanation
(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.

Question #37
An 8-year-old child comes to the physician’s office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?
  1. A
    A decreased urinary output and flank pain
  2. B
    A fever of over 103F occurring over the last 2–3 weeks
  3. C
    Rashes covering the palms of the hands and the soles of the feet
  4. D
    Headaches, malaise, or sore throat

Correct Answer:
D
(A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.

Question #38
The most commonly known vectors of Lyme disease are:
  1. A
    Mites
  2. B
    Fleas
  3. C
    Ticks
  4. D
    Mosquitoes

Correct Answer:
C
(A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease.
(D) Mosquitoes are not the common vector of Lyme disease.

Question #39
A laboratory technique specific for diagnosing Lyme disease is:
  1. A
    Polymerase chain reaction
  2. B
    Heterophil antibody test
  3. C
    Decreased serum calcium level
  4. D
    Increased serum potassium level

Correct Answer:
A
(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.

Question #40
The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
  1. A
    Complete bed rest for 6–8 weeks
  2. B
    Tetracycline treatment
  3. C
    IV amphotericin B
  4. D
    High-protein diet with limited fluids

Correct Answer:
B
(A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9.
(C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.

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