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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

A client is brought to the emergency department by a friend who states that the client has attempted suicide. When assessing a client who has attempted suicide by taking an overdose of medication, which question is most appropriate?

Correct Answer: C

Rationale: Identifying the drug is critical for determining the appropriate antidote or treatment to reverse the overdose.

Question 2 of 5

The nurse is caring for the client who is 24 hours post-TURP and is having painful bladder spasms. Which intervention should the nurse plan to implement?

Correct Answer: B

Rationale: A. Opioid medications will decrease the pain sensations but will not decrease the muscle spasms. B. The belladonna and opium suppository will inhibit smooth muscle contraction and decrease bladder spasms; thus, it will also reduce pain. C. Ambulation will not decrease the discomfort. D. Heat, rather than cold, is the recommended nonphannacological treatment for bladder spasms.

Question 3 of 5

The female nurse is sitting across a table from the Latino male she has been educating about testicular self-examination. When the client successfully verbalizes the process, the nurse excitedly praises the client, leans over the table, and makes the "OK" sign with her thumb and forefinger. The client angrily gets up and abruptly leaves the room. What likely caused the client's abrupt departure?

Correct Answer: C

Rationale: A. Since the client had participated in the discussion up to the point of the nurse's actions, he obviously was not uncomfortable with the discussion. B. A Latino is usually not uncomfortable with close personal space; some Latinos perceive Anglos as distant because they prefer more personal space during a conversation. C. In much of Latin America, the North American "OK" sign (i.e., pinched thumb and forefinger) may be considered obscene. D. Anger and an abrupt departure are usually not behaviors displayed by the client when teaching is completed.

Question 4 of 5

A client with type 2 diabetes mellitus reports feeling shaky and sweaty. The nurse checks the blood glucose level, which is 55 mg/dL. What is the nurse's priority action?

Correct Answer: B

Rationale: A blood glucose of 55 mg/dL indicates hypoglycemia; 15 g of a fast-acting carbohydrate (e.g., juice) is the priority to raise glucose levels.

Question 5 of 5

A client with a history of multiple sclerosis reports blurred vision. Which nursing intervention is most appropriate?

Correct Answer: D

Rationale: Blurred vision in multiple sclerosis may indicate optic neuritis, requiring specialist evaluation.

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