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NCLEX QUESTIONS Spring 2010 Set 2 (Answers follow all questions) Fundamentals of Nursing 1. The nurse has determined that a confused older adult client who keeps pulling out the intravenous line and indwelling catheter is in need of soft wrist restraints. Which of the following should the nurse include in this client's plan of care? A. Obtain a p.r.n. restraint order B. Assess the placement of the wrist restraints, skin, and circulation every hour and document C. Place the client in a supine position after applying the restraints and secure the wrist restraints to the side rails when the client is in bed D. Remove the restraints once every four hours to perform activities of daily living

Maternity 2. A pregnant client asks the nurse when the stretch marks will disappear. The most appropriate response by the nurse is: A. "They will disappear with the birth of the infant." B. "They will take up to six months to disappear." C. "They will fade but do not totally disappear." D. "They will disappear with a nutritionally balanced diet and exercise."

Pediatrics 3. The nurse caring for a child with neuroblastoma includes which of the following assessments as a measure of tumor responsiveness? A. Serum copper levels B. Erythrocyte sedimentation rate (ESR) C. Urine catecholamines D. Urinalysis with a culture and sensitivity

Neurological Disorders (Adult) 4. The nurse's plan of care for a client with Guillain-Barre syndrome is based on an understanding of which of the following disease processes? A. Decreased secretion of acetylcholine and an increase of cholinesterase at the myoneural junction B. Segmental demyelination of the ventral and dorsal nerve roots in the spinal cord and medulla

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C. Chronic inflammation, demyelination, and scarring of the CNS D. Decreased secretion of the neurotransmitter dopamine with an anticholinergic effect

Musculoskeletal/Integumentary Disorders (Adult) 5. When the first class of drugs prescribed for rheumatoid arthritis fails, the nurse anticipates which category of drugs will be prescribed? A. Nonsteroidal anti-inflammatory B. Disease-modifying antirheumatic C. Salicylates D. Biologic response modulators

Oncological/Immune Disorders (Adult) 6. The nurse is admitting a client with vaginal cancer. Which of the following questions should the nurse ask to elicit the most likely causative factor? A. "Did you experience your first menses before the age of 11 years?" B. "Did your mother take diethylstilbestrol (DES) during pregnancy?" C. "Have you ever taken tamoxifen?" D. "Do you have a history of a sexually transmitted disease?"

Cardiovascular Disorders (Adult) 7. In caring for a client with atrial flutter, which of the following goals would have priority? A. Reduce the ventricular rate to below 100 beats per minute B. Identify and treat the underlying cause C. Control the heart rate and maintain cardiac output D. Increase the heart rate

Respiratory Disorders (Adult) 8. Which of the following is a priority to include in the instructions given to a client who has bronchitis? A. Avoid cigarette smoking B. Decrease overweight status C. Increase activity D. Avoid malnutrition

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Endocrine Disorders (Adult) 9. The nurse assesses which of the following assessments in a client with severe anterior pituitary deficiency caused by the growth of a tumor? Select all that apply: A. Intolerance to heat B. Hyperglycemia C. Polyuria D. Bradycardia E. Hypoglycemia F. Dehydration

GI/GU Disorders (Adult) 10. The nurse is discharging a client with chronic pancreatitis. Which of the following measures would be essential to include in the client's discharge instruction? A. Weight reduction and exercise program B. Bowel retraining program including daily laxative administration C. Diet modifications avoiding high-fat foods, caffeine, and alcohol D. Relaxation techniques and stress management

Sensory Disorders (Adult) 11. The nurse should consider which of the following drugs taken by a client with glaucoma? A. Drugs that increase intraocular pressure B. Drugs that decrease intraocular pressure C. Drugs that decrease vitreous humor D. Drugs that cause anesthesia

Psychiatric and Mental Health (Adult) 12. Which of the following is an appropriate goal for the nurse caring for a client who has a diagnosis of borderline personality disorder? A. To identify irrational thoughts and beliefs that the client's decision making is founded on B. To eliminate boundaries between the client and nurse so the client can more easily share problems C. To eliminate the immediate focus on the client by encouraging the client to focus on relationships with others D. To eliminate the client's involvement in treatment planning because of the accompanying irrational thoughts and beliefs

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Answers 1. B: The standard of care for restraints is that they can be applied only with a written order from a health care provider. The order must be renewed every 24 hours. A p.r.n. order for restraints is not acceptable. Restraints should be removed once every two hours to perform activities of daily living. The client with wrist restraints should be placed in a lateral position to prevent aspiration. The condition of the skin, circulation, and placement of restraints must be assessed every hour. The assessment must also be documented.

2. C: The stretch marks a pregnant woman experiences will fade after the birth of the infant, but will not totally disappear.

3. C: Neuroblastoma is a tumor that originates from the adrenal medulla and sympathetic nervous system. Clients with neuroblastoma produce metabolites (VMS, HVA, dopamine). Serum copper levels and erythrocyte sedimentation rates are tumor markers for Hodgkin's disease. Urinalysis with culture and sensitivity is an assessment conducted when urinary tract infection is suspected.

4. B: Guillain-Barre syndrome, often referred to as postinfectious polyneuropathy, is a segmental demyelination of the ventral and dorsal nerve roots in the spinal cord and medulla. A decrease in acetylcholine at the neuromuscular junction is myasthenia gravis. Parkinson's disease is a decrease in the secretion of dopamine. A chronic inflammation, demyelination, and scarring of the CNS is characteristic of multiple sclerosis.

5. D: Disease-modifying antirheumatic drugs (DMARDs) are the first drugs used to try to reduce joint clinical manifestations in rheumatoid arthritis. Biologic response modulators have a 66% success rate after failure with DMARDs.

6. B: A client whose mother had taken diethylstilbestrol (DES) during pregnancy is more likely to develop vaginal cancer. There is no correlation with the age of the first menses, having taken tamoxifen, or having had a history of a sexually transmitted disease.

7. C: The goal for a client with atrial fibrillation is to reduce the ventricular response rate to below 100 beats per minute. An appropriate goal for a client with sinus tachycardia is to identify and treat the underlying cause. It is a priority to control the heart rate and maintain cardiac output in a client with atrial flutter. A goal of increasing the heart rate would be an appropriate goal for a client with a junctional rhythm.

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8. A: Cigarette smoking is one of the most significant risk factors for developing bronchitis. Bronchitis involves the major bronchi and is classified as acute or chronic. Acute bronchitis is bronchial airway inflammation related to smoke, irritants, or infection. Chronic bronchitis is a component of chronic obstructive pulmonary disease (COPD). It usually follows an upper respiratory infection such as rhinitis or sore throat. Malnutrition is considered a possible risk factor. Obesity or being active in sports is not correlated with bronchitis.

9. D, E: The anterior pituitary gland secretes several hormones, primarily ACTH, TSH, FSH, LH, and prolactin. A tumor in the anterior pituitary gland results in hyposecretion of one or more of the hormones secreted. Bradycardia would indicate a deficiency in thyroid hormones and hypoglycemia would indicate a deficiency in adrenocorticotrophic hormones. Intolerance to heat, characteristic of hyperthyroidism and hyperglycemia, would indicate an increase in ACTH. Polyuria would be characteristic of excessive secretion of ADH from the posterior pituitary or excessive secretion of ACTH. Dehydration and polyuria are characteristics of diabetes insipidus, a posterior pituitary disorder.

10. C: A diet low in fat and avoiding caffeine and alcohol are recommended for chronic pancreatitis. Weight reduction, exercise program, bowel retraining program, relaxation techniques, and stress management are not interventions pertinent to pancreatitis.

11. A: Glaucoma causes increased intraocular pressure, which can damage the optic nerve. The drugs used to treat glaucoma could decrease intraocular pressure by decreasing aqueous humor in the anterior chamber. An anesthetic would not reduce the intraocular pressure.

12. A: An appropriate goal for helping a client with borderline personality disorder is to focus on the client and the client's belief system to encourage an understanding of how those beliefs impact relationships. The client with borderline personality disorder is already focused on relationships with others, which continues the chaotic relationship. The client focuses on others and fails to focus on oneself. Once the client can distinguish between rational and irrational thoughts, the client can begin to evaluate surrounding relationships.

Reference Silvestri, L.A. (2008). Comprehensive Review for the NCLEX-RN Examination (4th edition). St Louis, MO: Saunders.

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