NCLEX Module 4 Exam ALL ANSWERS 100% CORRECT SPRING FALL-2022 SOLUTION GUARANTEED GRADE A+

A client with schizophrenia says, “I’m away for the day ... but don’t think we should play or do we have feet of clay?” Which alteration in the client’s speech does the nurse document? A. Neologism B. Word salad C. Clang association Correct D. Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the subject in the question, the meaningless rhyming of words. Review: these speech patterns . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 281). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition Awarded 100.0 points out of 100.0 possible points. 2. 2.ID: 90 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? A. Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” B. Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” C. Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct D. Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 297). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Adherence, Psychosis HESI Concepts: Adherence, Cognition Awarded 100.0 points out of 100.0 possible points. 3. 3.ID: 87 An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. “Try not to listen to the voices right now so that I can talk with you.” Correct B. “I think that you can help him stop his behavior if you concentrate.” C. “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” D. “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding, “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review: therapeutic communication techniques with a client who is hallucinating . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Awarded 100.0 points out of 100.0 possible points. 4. 4.ID: 84 A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by the nurse would be therapeutic? A. “What do you mean, ‘The whole thing is over’?” B. “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” C. “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” D. “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Awarded 100.0 points out of 100.0 possible points. 5. 5.ID: 81 The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. “No, I wasn’t, but I am now, thanks to you.” Correct B. “I hadn’t thought of that, but I can see that you are.” C. “Of course not, but there are days when I think that I should be.” D. “What is suicide going to do for me except get me excommunicated from the church?” Awarded 100.0 points out of 100.0 possible points. 6. 6.ID: 78 A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is most appropriate? A. “Good grief! You don’t look organized to me.” B. “Okay, what are you up to today? Your behavior is not appropriate.” C. “You talk about getting organized. Are you thinking of killing yourself?” Correct D. “If you keep behaving like this, you know that I’ll have to tell the health care provider, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t look organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, “If you keep behaving like this, you know that I’ll have to tell the health care provider and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review: the clues that indicate the potential for suicide . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 316). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Awarded 100.0 points out of 100.0 possible points. 7. 7.ID: 75 An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? A. “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct B. “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” C. “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” D. “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. This will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 683). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental Awarded 100.0 points out of 100.0 possible points. 8. 8.ID: 72 A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic? A. “What are you saying? Sounds like you need to pull yourself together and go back to school.” B. “Having faith in yourself is one thing, but looking at your alternatives realistically is another.” C. “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct D. “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating, “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options in that the nurse uses a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 94). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood & Affect Awarded 100.0 points out of 100.0 possible points. 9. 9.ID: 66 A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse give to the client? A. “Of course you can’t be left alone to get on with what you want to do.” B. “Okay, go ahead and do whatever you want to do. Human beings have free will.” C. “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct D. “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” Awarded 100.0 points out of 100.0 possible points. 10. 10.ID: 63 A client experiencing homelessness, with an antisocial disorder, is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide Correct Awarded 100.0 points out of 100.0 possible points. 11. 11.ID: 60 A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? A. Placing the client in a private room and locking the client’s closets and bathroom B. Placing the client in a private room and removing all knives and glass from the client’s meal tray C. Allowing the client to go out on pass as long as the client is accompanied by a responsible adult D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm’s distance from the client at all times Correct Awarded 100.0 points out of 100.0 possible points. 12. 12.ID: 56 A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention should the nurse implement? A. Restricting visitors B. Placing the client in a private room and locking the bathroom door C. Removing perfume, shampoo, and other toiletries from the client’s room Correct D. Placing flowers brought to the client in a small glass vase and putting them in the client’s room Awarded 100.0 points out of 100.0 possible points. 13. 13.ID: 53 A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, “My priest assaulted me when I was an altar boy, and my dad just found out. He’s got a gun, and he’s driving over to the church rectory. I don’t know what to do.” Which response by the nurse is most appropriate initially? A. “How did your dad learn of your abuse by clergy?” B. “Call the police immediately and then call the priest to warn him that your dad has a gun.” C. “Call the priest immediately and tell him to lock the doors until the police arrive. I’ll call the police.” Correct D. “You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened.” Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in this case, the duty to warn the priest of the danger he is facing is paramount. When violence erupts, the nurse must think and act quickly and with clarity. “How did your dad learn of your abuse by clergy?” is off focus and inappropriate to the situation. Telling the client, “Call the police immediately and then call the priest to warn him that your dad has a gun,” is incorrect, because the priest should be warned first. In stating, “You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened,” the nurse does not focus on the imminent violence described in the question. Test-Taking Strategy: Note the strategic words “most appropriate” and “initially.” Eliminate the comparable or alike options that direct the client to call the police first. To select from the remaining options, consider the seriousness of the situation. This will direct you to the correct option. The priest needs to be warned of the danger. Review: nursing responsibilities in violent situations . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 130, 131). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Safety, Sexuality HESI Concepts: Safety, Sexuality/Reproduction Awarded 100.0 points out of 100.0 possible points. 14. 14.ID: 50 The nurse determines that a client whose son died in a car accident is at risk for self- harm. Which intervention is most appropriate initially? A. Making a “no suicide” contract with the client Correct B. Telling the client that anger should be suppressed C. Providing a peaceful place for the client to meditate D. Helping the client control expression of his feelings Awarded 100.0 points out of 100.0 possible points. 15. 15.ID: 47 A client says to the nurse, “I’m worried about my husband. He’s talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he’s too intelligent to hurt himself, isn’t he?” Which response by the nurse is appropriate? A. “Yes, he’s too intelligent to end it all.” B. “I’m not sure. I don’t know him that well.” C. “Most people who talk about ending it all are just looking for attention.” D. “Your husband is displaying behaviors that indicate a risk for self- harm.” Correct Awarded 100.0 points out of 100.0 possible points. 16. 16.ID: 44 A client says to the nurse, “I came in to see you because I’ve been off my medication for 4 years but I feel as though I may be getting depressed again. I’ve been despondent again and thinking I should have ended it. That’s why I’m here to get help.” Which response by the nurse would be therapeutic? A. “Well, you really have had a good long drug-free time, but it sounds as if the health care provider needs to reorder your medication at once.” B. “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress.” C. “Well, it’s been more than 4 years, so you’ve done really well. Sounds like you’re right about getting depressed again, though. Can you tell me what’s been happening with you lately?” Correct D. “Well, it’s similar to when a client is battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the health care provider can restart the medication.” Rationale: The therapeutic response is the one in which the nurse validates the client’s drug-free time. In addition, in the correct option the nurse validates the client’s self- assessment and supports and offers positive reinforcement. Finally the nurse begins to assess the client completely and attempts to identify precipitants. By stating, “Well, you really have had a good long drug-free time, but it sounds as if the health care provider needs to reorder your medication at once,” the nurse is premature in determining that the medication needs to be restarted; a thorough assessment must be performed first. In stating, “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress,” the nurse jumps to giving advice and offering suggestions without performing a complete assessment. In stating, “Well, it’s similar to when a client gets battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the health care provider can restart the medication,” the nurse provides an incorrect statement and sarcastic information. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and the steps of the nursing process, remembering that assessment is the first step. The only option that involves the process of assessment is the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 286-287). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 221). St. Louis: Saunders. Level of Cognitive Ability: Applying Awarded 100.0 points out of 100.0 possible points. 17. 17.ID: 41 A client who delivered a baby 4 months ago says, “I keep thinking that this boy is some sort of demon. All he does is cry. It’s as if I can’t feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can’t stand it.” Which statement by the nurse is most important? A. “Have you been having any thoughts of hurting your baby?” Correct B. “Do you think that something physically wrong is causing your baby to cry?” C. “Do you think that your baby cries so frequently because he’s not getting enough nourishment from breastfeeding?” D. “You say that he doesn’t seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?” Awarded 100.0 points out of 100.0 possible points. 18. 18.ID: 38 A client who is an alcoholic, has been admitted to the mental health unit states to the nurse, “The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car.” Which statement by the nurse is most appropriate? A. “Did you ask the judge to clarify his decision to make you come here?” B. “This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level.” C. “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” D. “This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here.” Correct Rationale: In most states (although the blood alcohol level, or BAL—designated as the indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his blood alcohol level and directs him to focus on his action and behaviors. In asking, “Did you ask the judge to clarify his decision to make you come here?” the nurse seeks clarification from the client, which closes off the expression of feelings by changing the focus of the discussion. In stating, “This reading means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level,” the nurse gives inaccurate information about the BAL. In responding, “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” the nurse gives opinions and is judgmental, then asks for agreement in a sarcastic style of communication. Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of BAL. Recalling that in most states the legal alcohol limit is 0.08% will direct you to the correct option. Review: the BAL . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 419). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Addiction, Communication HESI Concepts: Behaviors, Communication Awarded 100.0 points out of 100.0 possible points. 19. 19.ID: 35 An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A. A situational crisis B. An individual crisis C. A maturational crisis Correct D. An adventitious crisis Awarded 100.0 points out of 100.0 possible points. 20. 20.ID: 32 A person who has overdosed on heroin is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? A. Gastric lavage B. Intravenous fluid C. Naloxone Correct D. Ammonium chloride Awarded 100.0 points out of 100.0 possible points. 21. 21.ID: 29 A client in a retirement center rings the night alarm and says to the nurse, “Look at this old man! He keeps breaking into my apartment! You’ve got to get him to stay out of here so I can sleep.” Which statement by the nurse would be most therapeutic? A. “Why not just throw him out yourself and lock up once and for all?” B. “Now, you know that you’re always seeing things and people at night who aren’t there.” C. “This must be very troubling to you, but I can’t see the old man. Perhaps I could stay with you for an hour or so while you try to rest.” Correct D. “I’m sure you’re very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he’ll leave your apartment.”