A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?

Depersonalization

Hallucination

Illusion

Derealization

Answer and Explanation

The Correct Answer is B

A.   Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B.   Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C.   Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D.   Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.

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Correct Answer is B

Explanation

A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.

D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.

A. Suction device B. Infusion pump C. Disposable feeding bag D. Sterile gloves

Correct Answer is A

Explanation

A. A suction device is necessary for the nasogastric tube insertion procedure to remove gastric contents and ensure the tube is correctly placed in the stomach.
B. An infusion pump is not typically required for nasogastric tube insertion.
C. A disposable feeding bag is used for enteral feeding and is not directly related to the insertion of a nasogastric tube.
D. Sterile gloves are not typically used during nasogastric tube insertion, as it is a clean procedure rather than a sterile one.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric tube. Which of the following equipment should the nurse gather prior to the procedure?

Correct Answer is A

Explanation

A nurse is providing preoperative teaching for an adolescent who is scheduled for a cardiac catheterization. Which of the following Instructions should the nurse include?

A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?

A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively?

A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?

A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the following actions should the nurse plan to take?

A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care?

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?