NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
Question 2 of 5
A client tells the nurse that he is going to harm his brother-in-law, who called the police on him for threatening to hurt his ex-wife. The nurse should notify which of the following persons? Select all that apply.
Correct Answer: C,D
Rationale: The nurse has a duty to warn the intended victim (brother-in-law) and notify the police due to the credible threat of harm. Notifying administrators or social services may be secondary, and the ex-wife is not the current target.
Question 3 of 5
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
Question 4 of 5
The nurse is teaching a client about the use of a peak flow meter for asthma management. The client should be instructed to:
Correct Answer: B
Rationale: Recording the highest of three peak flow readings provides the most accurate assessment of lung function for asthma monitoring.
Question 5 of 5
A client with a history of hypothyroidism is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
Correct Answer: A, B
Rationale: Hypothyroidism presents with elevated TSH and decreased free T4.