NCLEX PN ARCHER REVIEW
The nurse is caring for a client exhibiting signs of poor muscle coordination, stooped posture,
and slow movements. Which medication is most likely to cause these symptoms?
Haloperidol
Rationale:
Haloperidol is a typical antipsychotic that may adversely cause extrapyramidal side effects
(EPS). These effects include akathisia, dystonia, pseudo-parkinsonism, and/or tardive
dyskinesia. Tardive dyskinesia is an adverse effect that occurs with antipsychotics and has an
onset of months to years while on the medication.
While reviewing the morning labs of your client, you see the following results from their thyroid
panel. What diagnosis does the nurse suspect?
TSH: 7 mU/L
T4: 1.0 mcg/dL
T3: 2.0 ng/dL
Hypothyroidism
Rationale:
Hypothyroidism would be manifested with an increased thyroid-stimulating hormone level and
decreased T4 and T3, as shown in these labs. Because of the increased TSH level, the thyroid
gland is tricked into thinking that there is enough thyroid hormone already in the body and does
not secrete more. The decreased T3 and T4 levels cause hypothyroidism symptoms, such as
weight gain and fatigue.
The nurse reinforces teaching to a client with hypertension about the newly prescribed
furosemide. Which of the following should the nurse include in the teaching?
,Take this medication in the early part of the day
Rationale:
Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or
hypertension. The client should be instructed to take this medication in the earlier part of the day
to avoid nocturia.
The nurse is assessing a 7-month-old infant. At this age, which of the following reflexes would
the nurse expect to no longer be present?
Select all that apply.
Rooting
Moro
Palmar
Tonic neck
Rationale:
- The Rooting reflex should disappear by 3-4 months of age. It occurs when the infants turn their
face toward stimulation (such as stroking their cheek) and make sucking (rooting) motions with
the mouth. This reflex helps to ensure successful feeding.
- The Moro reflex should disappear by 5-6 months of age. This reflex is a response to a sudden
loss of support. When support is removed, the infant spreads out the arms and cries.
- The Palmar reflex should disappear by 2-3 months of age. When an object is placed in an
infant's hand, and the palm is stroked, the fingers will close reflexively.
- The tonic neck reflex disappears around 4 months of age. This reflex is elicited by turning the
infant's head to one side and is considered positive if the infant extends the extremities on the
side that the head is turned toward, and flexes the extremities on the opposite side.
The nurse is caring for a client with diabetes mellitus. Which of the following laboratory data
requires follow-up?
,Select all that apply.
Hemoglobin A1C 8.5% [< 5.7%]
Creatinine 1.9 mg/dL [0.6-1.2 mg/dL]
BUN 25 mg/dL [10-20 mg/dL]
Proteinuria
Rationale:
The client's hemoglobin A1C is elevated as the therapeutic goal for a client with diabetes is to
attain less than 7%. This elevated level is causing the client to experience an insult to the
kidneys, which is evident by the increased BUN (normal 10-20 mg/dL) and creatinine (normal
0.6-1.2 mg/dL). Finally, proteinuria is further evidence that this client is experiencing diabetic
nephropathy.
The nurse is caring for the following assigned clients. Which client should the nurse follow up
with first?
A client requesting diphenhydramine after starting an intravenous antibiotic.
Rationale:
A client requesting diphenhydramine following the initiation of an antibiotic requires immediate
follow-up because the client could be experiencing an allergic reaction ranging from mild to
severe. Thus, the nurse should quickly follow-up with this client.
The nurse is assessing a 6-year-old client with asthma. Which of the following findings is of
highest concern?
Silent chest
Rationale:
Silent chest is the assessment finding of most concern. This refers to the inability to auscultate
any lung sounds. There is complete obstruction of the client's airway, and therefore the inability
to move air. When complete obstruction occurs, this is a medical emergency. This assessment
finding is of most concern because the client has lost their airway.
, The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this
medication is indicated for which condition?
Insomnia
Rationale:
Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia.
*NGN* The nurse is caring for a 47-year-old male in the outpatient clinic
Orders
Discharge home
Schedule a follow-up appointment in four weeks
Sertraline 50 mg PO Daily
Clonidine 0.1 mg PO Daily
Zolpidem 5 mg PO, PRN insomnia
The nurse reviews the orders and formulates a teaching plan for the newly prescribed
medications
For each medication, select the appropriate option for drug classification and client teaching that
should be reinforced
Clonidine - alpha2-adrenergic agonist
This medication may cause you to become dizzy or tired.
Sertraline - selective serotonin reuptake inhibitor
Diarrhea is a common side effect of this medication.
Zolpidem - Hypnotic
The nurse is caring for a client exhibiting signs of poor muscle coordination, stooped posture,
and slow movements. Which medication is most likely to cause these symptoms?
Haloperidol
Rationale:
Haloperidol is a typical antipsychotic that may adversely cause extrapyramidal side effects
(EPS). These effects include akathisia, dystonia, pseudo-parkinsonism, and/or tardive
dyskinesia. Tardive dyskinesia is an adverse effect that occurs with antipsychotics and has an
onset of months to years while on the medication.
While reviewing the morning labs of your client, you see the following results from their thyroid
panel. What diagnosis does the nurse suspect?
TSH: 7 mU/L
T4: 1.0 mcg/dL
T3: 2.0 ng/dL
Hypothyroidism
Rationale:
Hypothyroidism would be manifested with an increased thyroid-stimulating hormone level and
decreased T4 and T3, as shown in these labs. Because of the increased TSH level, the thyroid
gland is tricked into thinking that there is enough thyroid hormone already in the body and does
not secrete more. The decreased T3 and T4 levels cause hypothyroidism symptoms, such as
weight gain and fatigue.
The nurse reinforces teaching to a client with hypertension about the newly prescribed
furosemide. Which of the following should the nurse include in the teaching?
,Take this medication in the early part of the day
Rationale:
Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or
hypertension. The client should be instructed to take this medication in the earlier part of the day
to avoid nocturia.
The nurse is assessing a 7-month-old infant. At this age, which of the following reflexes would
the nurse expect to no longer be present?
Select all that apply.
Rooting
Moro
Palmar
Tonic neck
Rationale:
- The Rooting reflex should disappear by 3-4 months of age. It occurs when the infants turn their
face toward stimulation (such as stroking their cheek) and make sucking (rooting) motions with
the mouth. This reflex helps to ensure successful feeding.
- The Moro reflex should disappear by 5-6 months of age. This reflex is a response to a sudden
loss of support. When support is removed, the infant spreads out the arms and cries.
- The Palmar reflex should disappear by 2-3 months of age. When an object is placed in an
infant's hand, and the palm is stroked, the fingers will close reflexively.
- The tonic neck reflex disappears around 4 months of age. This reflex is elicited by turning the
infant's head to one side and is considered positive if the infant extends the extremities on the
side that the head is turned toward, and flexes the extremities on the opposite side.
The nurse is caring for a client with diabetes mellitus. Which of the following laboratory data
requires follow-up?
,Select all that apply.
Hemoglobin A1C 8.5% [< 5.7%]
Creatinine 1.9 mg/dL [0.6-1.2 mg/dL]
BUN 25 mg/dL [10-20 mg/dL]
Proteinuria
Rationale:
The client's hemoglobin A1C is elevated as the therapeutic goal for a client with diabetes is to
attain less than 7%. This elevated level is causing the client to experience an insult to the
kidneys, which is evident by the increased BUN (normal 10-20 mg/dL) and creatinine (normal
0.6-1.2 mg/dL). Finally, proteinuria is further evidence that this client is experiencing diabetic
nephropathy.
The nurse is caring for the following assigned clients. Which client should the nurse follow up
with first?
A client requesting diphenhydramine after starting an intravenous antibiotic.
Rationale:
A client requesting diphenhydramine following the initiation of an antibiotic requires immediate
follow-up because the client could be experiencing an allergic reaction ranging from mild to
severe. Thus, the nurse should quickly follow-up with this client.
The nurse is assessing a 6-year-old client with asthma. Which of the following findings is of
highest concern?
Silent chest
Rationale:
Silent chest is the assessment finding of most concern. This refers to the inability to auscultate
any lung sounds. There is complete obstruction of the client's airway, and therefore the inability
to move air. When complete obstruction occurs, this is a medical emergency. This assessment
finding is of most concern because the client has lost their airway.
, The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this
medication is indicated for which condition?
Insomnia
Rationale:
Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia.
*NGN* The nurse is caring for a 47-year-old male in the outpatient clinic
Orders
Discharge home
Schedule a follow-up appointment in four weeks
Sertraline 50 mg PO Daily
Clonidine 0.1 mg PO Daily
Zolpidem 5 mg PO, PRN insomnia
The nurse reviews the orders and formulates a teaching plan for the newly prescribed
medications
For each medication, select the appropriate option for drug classification and client teaching that
should be reinforced
Clonidine - alpha2-adrenergic agonist
This medication may cause you to become dizzy or tired.
Sertraline - selective serotonin reuptake inhibitor
Diarrhea is a common side effect of this medication.
Zolpidem - Hypnotic
