NCLEX RN EXAM/PREPARATION
Question 1
WRONG
Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the
client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?
A Assume that the client is posturing.
B Tell the client to lie down and relax.
Evaluate the client for adverse reactions to haloperidol.
Put the client on the list for the physician to see tomorrow
Question 1 Explanation:
An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes
legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for
related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and
jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms.
When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible
cause and obtain treatment immediately, rather than have the client wait.
Question 2
WRONG
The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the
tablet form because the liquid:
has a more predictable onset of action.
B produces fewer anticholinergic effects.
produces fewer drug interactions.
D has a longer duration of action.
Question 2 Explanation:
A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.
Question 3
WRONG
Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s
interpersonal communication with the client and specific nursing interventions must be:
clearly identified with boundaries and specifically defined
A roles.
B warm and nonthreatening.
centered on clearly defined limits and expression of empathy.
flexible enough for the nurse to adjust the plan of care as the
situation warrants.
Question 3 Explanation:
A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who
has a thought disorder. Because such a client communicates at different levels and is in control of himself at various
times, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear; however,
the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia
fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering
interventions on clearly defined limits is impossible because the client’s situation may change without warning.
Question 4
WRONG
The definition of nihilistic delusions is:
A a false belief about the functioning of the body.
B belief that the body is deformed or defective in a specific way.
false ideas about the self, others, or the world
the inability to carry out motor activities.
Question 4 Explanation:
1
, NCLEX RN EXAM/PREPARATION
Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the
functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective
in a specific way. Apraxia is the inability to carry out motor activities.
Question 5
WRONG
A client who has been hospitalized with disorganized type schizophrenia for 8 years can’t complete activities of daily
living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient:
Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?
“Client will be able to complete ADLs independently within 1
A month.”
“Client will be able to complete ADLs with only verbal
B encouragement within 1 month.”
“Client will be able to complete ADLs with assistance in
organizing grooming items and clothing within 1 month.”
“Client will be able to complete ADLs with complete
assistance within 1 month.”
Question 5 Explanation:
The client’s disorganized personality and history of hospitalization have affected the ability to perform self-care
activities. Interventions should be directed at helping the client complete ADLs with the assistance of staff members,
who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic
independence. As the client improves and achieves the established goal, the nurse can set new goals that focus on the
client completing ADLs with only verbal encouragement and, ultimately, completing them independently. The client’s
condition doesn’t indicate a need for complete assistance, which would only foster dependence.
Question 6
WRONG
A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during
social situations?
A Aggressive behavior
Paranoid thoughts
C Emotional affect
Independence needs
Question 6 Explanation:
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is
emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for
close or dependent relationships.
Question 7
CORRECT
A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of
eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?
Telling the client that she may become sick and die unless she
A eats
Paying special attention to the client’s rituals and emotions
B associated with meals
Restricting the client’s access to food except at specified meal
and snack times
D Encouraging the client to express her feelings at meal times
Question 7 Explanation:
Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or
depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become
sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and
emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at
meal times would increase the association between emotions and food; instead, the nurse should encourage her to
express feelings at other times.
Question 8
CORRECT
2
Question 1
WRONG
Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the
client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?
A Assume that the client is posturing.
B Tell the client to lie down and relax.
Evaluate the client for adverse reactions to haloperidol.
Put the client on the list for the physician to see tomorrow
Question 1 Explanation:
An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes
legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for
related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and
jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms.
When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible
cause and obtain treatment immediately, rather than have the client wait.
Question 2
WRONG
The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the
tablet form because the liquid:
has a more predictable onset of action.
B produces fewer anticholinergic effects.
produces fewer drug interactions.
D has a longer duration of action.
Question 2 Explanation:
A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.
Question 3
WRONG
Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s
interpersonal communication with the client and specific nursing interventions must be:
clearly identified with boundaries and specifically defined
A roles.
B warm and nonthreatening.
centered on clearly defined limits and expression of empathy.
flexible enough for the nurse to adjust the plan of care as the
situation warrants.
Question 3 Explanation:
A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who
has a thought disorder. Because such a client communicates at different levels and is in control of himself at various
times, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear; however,
the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia
fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering
interventions on clearly defined limits is impossible because the client’s situation may change without warning.
Question 4
WRONG
The definition of nihilistic delusions is:
A a false belief about the functioning of the body.
B belief that the body is deformed or defective in a specific way.
false ideas about the self, others, or the world
the inability to carry out motor activities.
Question 4 Explanation:
1
, NCLEX RN EXAM/PREPARATION
Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the
functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective
in a specific way. Apraxia is the inability to carry out motor activities.
Question 5
WRONG
A client who has been hospitalized with disorganized type schizophrenia for 8 years can’t complete activities of daily
living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient:
Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?
“Client will be able to complete ADLs independently within 1
A month.”
“Client will be able to complete ADLs with only verbal
B encouragement within 1 month.”
“Client will be able to complete ADLs with assistance in
organizing grooming items and clothing within 1 month.”
“Client will be able to complete ADLs with complete
assistance within 1 month.”
Question 5 Explanation:
The client’s disorganized personality and history of hospitalization have affected the ability to perform self-care
activities. Interventions should be directed at helping the client complete ADLs with the assistance of staff members,
who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic
independence. As the client improves and achieves the established goal, the nurse can set new goals that focus on the
client completing ADLs with only verbal encouragement and, ultimately, completing them independently. The client’s
condition doesn’t indicate a need for complete assistance, which would only foster dependence.
Question 6
WRONG
A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during
social situations?
A Aggressive behavior
Paranoid thoughts
C Emotional affect
Independence needs
Question 6 Explanation:
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is
emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for
close or dependent relationships.
Question 7
CORRECT
A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of
eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?
Telling the client that she may become sick and die unless she
A eats
Paying special attention to the client’s rituals and emotions
B associated with meals
Restricting the client’s access to food except at specified meal
and snack times
D Encouraging the client to express her feelings at meal times
Question 7 Explanation:
Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or
depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become
sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and
emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at
meal times would increase the association between emotions and food; instead, the nurse should encourage her to
express feelings at other times.
Question 8
CORRECT
2
