NCLEX Questions, NCLEX RN Nursing Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Nursing Exam Questions

Extract:


Question 1 of 5

A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:

Correct Answer: C

Rationale: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.

Question 2 of 5

The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:

Correct Answer: C

Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.

Question 3 of 5

A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:

Correct Answer: D

Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.

Question 4 of 5

A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:

Correct Answer: D

Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.

Question 5 of 5

Which nursing intervention would be of highest priority when caring for a patient admitted in sickle cell vaso-occlusive crisis?

Correct Answer: D

Rationale: In sickle cell vaso-occlusive crisis severe pain results from blocked blood vessels. Administering pain medication is the highest priority to relieve acute discomfort and improve patient comfort. While IV fluids and oxygen are important pain management is the most urgent need.

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