NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client is admitted to the inpatient unit and is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity. The client states, 'I am the Savior of the city.' The family states that the client is a public client in the United States. The nurse should further assess the client for which of the following?
Correct Answer: B
Rationale: Pressured speech, labile affect, euphoria, hyperactivity, and grandiose delusions (e.g., 'Savior of the city') are hallmark symptoms of the manic phase of bipolar disorder.
Question 2 of 5
A client with a history of rheumatoid arthritis is admitted with a flare-up. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: NSAIDs reduce inflammation and pain during rheumatoid arthritis flare-ups.
Question 3 of 5
When developing the plan of care for a client with Alzheimer's disease, which of the following activities is least beneficial to the client?
Correct Answer: D
Rationale: Stress management is least beneficial for Alzheimer's clients, as cognitive impairment limits their ability to engage in such activities. Reminiscence, walking, and pet therapy support engagement and well-being.
Question 4 of 5
A client with a history of alcohol abuse is admitted with confusion and tremors. The nurse should prepare to administer which medication?
Correct Answer: A
Rationale: Thiamine is administered to prevent Wernicke's encephalopathy, a neurological complication of alcohol withdrawal associated with confusion and tremors.
Question 5 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.