NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
A client admitted to the psychiatric unit claims to be the 'Son of God' and insists that he will not be confined by 'mere mortals.' The most likely explanation for the client's delusions is:
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the 'Son of God,' often stem from low self-esteem, compensating with inflated self-perception. Religious conversion, stress, or anxiety are less likely causes.
Question 2 of 5
The nurse has just returned to the desk and has four phone messages to return.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
Question 3 of 5
Four clients have signaled with their call bell for the nurse. Who should the nurse observe first?
Correct Answer: C
Rationale: A client recently given penicillin is at risk for an allergic reaction, including anaphylaxis, requiring immediate observation. Bathroom assistance, pain, or chair positioning are less urgent.
Question 4 of 5
A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of atrial fibrillation about diltiazem (Cardizem). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Taking diltiazem with grapefruit juice is incorrect, as it increases drug levels, risking toxicity. Options A, B, and D are correct: pulse monitoring detects bradycardia, leg swelling may indicate heart failure, and avoiding driving with dizziness prevents accidents.