which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective di
Logo

Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?

Correct answer: C

Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.

2. The patient in the emergency room has a history of alprazolam (Xanax) abuse and abruptly stopped taking Xanax about 24 hours ago. He presents with visible tremors, pacing, fear, impaired concentration, and memory. Which intervention takes priority?

Correct answer: A

Rationale: The 1-4 day period after Xanax withdrawal is critical as it poses the highest risk of life-threatening seizures. Alprazolam is a benzodiazepine, and sudden cessation can lead to severe withdrawal symptoms. The patient's visible tremors, fear, pacing, and cognitive impairment indicate a state of heightened distress and potential seizure risk. Placing the patient on a stretcher with raised bed rails is essential for seizure precautions, ensuring safety and preventing injury during a potential seizure. Offering water and food, reassuring the patient, or informing the physician about Xanax withdrawal are not immediate priorities compared to managing the risk of seizures in this high-risk situation.

3. Mr. C is brought to the hospital with severe burns over 45% of his body. His heart rate is 124 bpm and thready, BP 84/46, respirations 24/minute and shallow. He is apprehensive and restless. Which of the following types of shock is Mr. C at highest risk for?

Correct answer: B

Rationale: Mr. C, who has severe burns over 45% of his body, is at highest risk for hypovolemic shock. Burns lead to a loss of plasma volume, reducing the circulating fluid volume and impairing perfusion to vital organs and extremities. In this scenario, the signs of shock, such as increased heart rate, low blood pressure, shallow respirations, and restlessness, indicate a state of hypovolemic shock due to significant fluid loss. Septic shock (choice A) is primarily caused by severe infections, neurogenic shock (choice C) results from spinal cord injuries, and cardiogenic shock (choice D) stems from heart failure. However, in this case, the presentation aligns most closely with hypovolemic shock due to the extensive burn injury and its effects on fluid volume and perfusion.

4. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

Correct answer: B

Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.

5. A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nurse questions the patient on their usual routine at home. Which of these statements would alert the nurse that additional teaching is required?

Correct answer: A

Rationale: The correct answer is, 'I avoid NSAIDs. I only take a daily aspirin for my heart health.' Aspirin is classified as an NSAID and can exacerbate existing stomach problems, such as gastritis. Therefore, patients with gastritis should avoid aspirin just like any other NSAID. Choice B, 'I always avoid eating hot and spicy foods,' is a good practice for a patient with gastritis. Choice C, 'I will continue taking my antacids with or immediately after meals,' indicates understanding of the correct timing for antacid use. Choice D, 'I will only drink coffee once a week, if even that often,' shows a suitable limitation of coffee intake, which is beneficial for patients with gastritis.

Similar Questions

A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?
Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect?
Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
A patient has come into the emergency room after an injury at work in which their upper body was pinned between two pieces of equipment. The nurse notes bruising in the upper abdomen and chest. The patient is complaining of sharp chest pain, having difficulty breathing, and their trachea is deviated to the left side. Which of the following conditions are these symptoms most closely associated with?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses