NCLEX-RN Updated 2022, Complete Questions & Answers with rationale
NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase
(MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
A. 10 days
B. 2-4 weeks
C. 2 months
D. 3 months
(A) This answer is incorrect. It can take up to 1 month for the therapeutic effect of the medication.
(B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted.
(C) This answer is incorrect. It can take up to 1 month for the therapeutic effect of the medication.
(D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy.
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.
NO.3 A 24-year-old client presents to the emergency department protesting “I am God.” The nurse identifies this as a:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or
even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to lithium, which one of the following medications might the physician prescribe?
A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for the client to exercise.
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.