NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Extract:


Question 1 of 5

A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?

Correct Answer: C

Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.

Question 2 of 5

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?

Correct Answer: C

Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.

Question 3 of 5

A client with emphysema comes for a routine follow-up visit. The nurse assisting with the initial assessment knows that which manifestations are characteristic of emphysema? Select all that apply.

Correct Answer: A,C,D

Rationale: Emphysema causes air trapping, leading to barrel chest (
A), reduced exercise capacity (
C), and diminished breath sounds (
D). Crackles (
B) suggest fluid, and sputum (E) is more typical of chronic bronchitis.

Question 4 of 5

A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action?

Correct Answer: A

Rationale: Chlorhexidine (
A) is not standard for stethoscope cleaning in contact precautions; alcohol or approved disinfectants are used to prevent MRSA transmission. Sealed bags for specimens (
B), scrubbing the port (
C), and hand hygiene (
D) are correct actions to maintain infection control.

Question 5 of 5

The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?

Correct Answer: C

Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (
C). Auditory hallucinations (
A) involve hearing voices, not reference. Tactile hallucinations (
B) involve false sensations, and persecutory delusions (
D) involve belief in harm without reference to neutral stimuli.

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