Questions 150

NCLEX-RN

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Extract:


Question 1 of 5

During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?

Correct Answer: A

Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.

Question 2 of 5

A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?

Correct Answer: A

Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.

Question 3 of 5

A client with a history of type 2 diabetes mellitus is prescribed liraglutide (Victoza). The nurse should monitor the client for which of the following side effects?

Correct Answer: B

Rationale: Liraglutide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.

Question 4 of 5

The home care nurse notes that an older client is prescribed cimetidine. On assessment of the client, the nurse should check for which side effect of this medication?

Correct Answer: B

Rationale: Cimetidine is a gastric acid secretion inhibitor. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, agitation, and hallucinations. None of the remaining options are associated with the use of this medication.

Question 5 of 5

The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:

Correct Answer: B

Rationale: Aminophylline, a bronchodilator, is effective when it relaxes bronchial smooth muscles, improving airflow in emphysema.

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