NCLEX Questions, NCLEX Trainer Test 8 Questions, NCLEX-PN Questions, Nurselytic

Questions 156

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Question 1 of 5

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to

Correct Answer: A

Rationale: Notify the primary care provider immediately. The client’s suicidal intent and plan require immediate intervention by the healthcare team.

Question 2 of 5

The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

Correct Answer: D

Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.

Question 3 of 5

A young adult is admitted with a diagnosis of Guillain-Barré syndrome. Which nursing action will be of highest priority as the nurse plans care?

Correct Answer: B

Rationale: Guillain-Barré syndrome can cause ascending paralysis, risking respiratory muscle weakness; monitoring respirations is critical to detect respiratory failure early.

Question 4 of 5

The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following symptoms should the nurse report immediately?

Correct Answer: C

Rationale: Suicidal thoughts are a medical emergency with venlafaxine. Options A, B, and D are common side effects.

Question 5 of 5

A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?

Correct Answer: A

Rationale: The frontal lobe is responsible for behavior and emotions.

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