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Questions 158

NCLEX-RN

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Question 1 of 5

A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, 'My doctor is in love with me and wants to marry me.' This client is using which of the following defense mechanisms?

Correct Answer: B

Rationale: Displacement involves transferring feelings to a more acceptable object. Projection involves attributing one's thoughts or feelings to another person. Reaction formation involves transforming an unacceptable impulse into the opposite behavior. Suppression involves the intentional exclusion of unpleasant thoughts or experiences.

Question 2 of 5

The nurse has just received a report from the previous shift.

Correct Answer: B

Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. COPD with PCO2 50 (
A) is stable, pain (
C) is less urgent, and mild fever (
D) is expected post-op.

Question 3 of 5

The nurse is caring for a client with a diagnosis of placenta previa. Which symptom is most characteristic?

Correct Answer: A

Rationale: Placenta previa causes painless vaginal bleeding due to the placenta covering the cervix. Painful bleeding suggests abruptio placenta and fetal heart rate or fever are not specific to previa.

Question 4 of 5

A client with a history of a colostomy is being discharged. The nurse should teach the client to:

Correct Answer: B

Rationale: High-fiber foods can cause blockages or excessive output in a colostomy. Bag changes depend on output, alcohol irritates the stoma, and irrigation is not always required.

Question 5 of 5

The nurse is caring for a client who is receiving oxytocin for labor induction. The fetal heart rate shows variable decelerations. The nurse’s first action should be to:

Correct Answer: B

Rationale: Variable decelerations suggest umbilical cord compression. Repositioning the client (e.g. to the left side or knee-chest position) may relieve compression and is the first action. Stopping oxytocin or notifying the physician may be needed if repositioning is ineffective.

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