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Questions 149

NCLEX-PN

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Extract:


Question 1 of 5

A man who is being treated for paranoia walks toward the nurse's desk and observes the nurse making a telephone call. A few minutes later, he accuses the nurse of having called the police. How should the nurse interpret his behavior?

Correct Answer: D

Rationale: Interpreting a neutral action (phone call) as personally threatening indicates ideas of reference, a common feature of paranoia.

Question 2 of 5

An 88-year-old woman in a long-term care facility is having difficulty remembering where her room is. Which of the following solutions would best help her?

Correct Answer: C

Rationale: A picture and name in large letters provide a clear, recognizable cue for the woman to identify her room, supporting independence despite memory challenges.

Question 3 of 5

A client with terminal cancer yells at the nurse and says, 'I don't need your help, I can bathe myself.' Which stage of grief is the client most likely experiencing?

Correct Answer: C

Rationale: Yelling and asserting independence reflect anger, a stage of grief where clients may express frustration about their terminal condition.

Question 4 of 5

A woman is admitted to the detoxification unit. She admits to drinking increasingly larger amounts of alcohol for the past five years. What question is most important for the nurse to ask initially?

Correct Answer: B

Rationale: Knowing the time of the last drink is critical to anticipate the onset of withdrawal symptoms, which can be life-threatening.

Question 5 of 5

A client with severe anxiety manifested by many somatic complaints starts psychotherapy. She becomes increasingly anxious, and her physical symptoms intensify. The nurse should make which of these interpretations of her observations?

Correct Answer: C

Rationale: Increased anxiety and symptoms are common early in psychotherapy as clients confront underlying issues, an expected response.

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