Nclex2
1. . The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness." D) "You’re safe here. I won’t let anyone poison you."
A: "You think that someone wants to poison you?" This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.
2. . A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
A) Altered nutrition: less than body requirements B) Potential complication hemorrhage
C) Ineffective individual coping D) Fluid volume excess
B: Potential complication hemorrhage , Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
3. . The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sippy cup
The correct answer is D: A 30 month-old only drinking from a sippy cup
A 30 month-old should be able to drink from a cup without a cover. 4. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
A) Neuromalignant syndrome B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors
The correct answer is C: Glaucoma, prostatic hypertrophy
Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) as the drug is an anticholinergic agent.
5. A 15 year-old client with a lengthy confining illness is at risk for
A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness." D) "You’re safe here. I won’t let anyone poison you."
A: "You think that someone wants to poison you?" This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.
2. . A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
A) Altered nutrition: less than body requirements B) Potential complication hemorrhage
C) Ineffective individual coping D) Fluid volume excess
B: Potential complication hemorrhage , Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
3. . The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sippy cup
The correct answer is D: A 30 month-old only drinking from a sippy cup
A 30 month-old should be able to drink from a cup without a cover. 4. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
A) Neuromalignant syndrome B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors
The correct answer is C: Glaucoma, prostatic hypertrophy
Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) as the drug is an anticholinergic agent.
5. A 15 year-old client with a lengthy confining illness is at risk for