NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
Question 2 of 5
A 12-year-old boy is admitted due to depression and post-trauma response. Child Protective Services reports that the boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
Correct Answer: A, B, C, D, E
Rationale: Incest victims may exhibit sexualized play, aggression, isolation, running away, and truancy as coping mechanisms or trauma responses.
Question 3 of 5
The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?
Correct Answer: C
Rationale: Tapering TPN prevents rebound hypoglycemia by allowing the body to adjust to reduced glucose infusion.
Question 4 of 5
A client is admitted to the hospital with a tentative diagnosis of urinary tract infection (UTI). The nurse should assess the client for which of the following as a precipitating factor for the UTI?
Correct Answer: D
Rationale: Frequent sexual intercourse is a common precipitating factor for UTIs, as it can introduce bacteria into the urinary tract.
Question 5 of 5
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.