NCLEX Questions, NCLEX PN Exam Practice Test with NGN Questions, NCLEX-PN Questions, Nurselytic

Questions 85

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Exam Practice Test with NGN Questions

Extract:



Question 1 of 5

For each event, click to specify whether the event is a sentinel event or a near-miss event.

Correct Answer: A,B,E,F

Rationale: Sentinel events cause harm: fall with fracture , wrong-site procedure , suicide , and anaphylaxis . Near-misses (C,
D) are caught before harm.

Extract:

The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur


Question 2 of 5

Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply

Correct Answer: A,B,C

Rationale: Alprazolam requires avoiding driving , monitoring for suicidal thoughts , and gradual tapering . Alcohol limits are stricter, and sertraline is not for acute attacks.

Extract:

The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.


Question 3 of 5

For each intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.

Correct Answer: A,C,E

Rationale: Music , transparent medication administration , and assessing self-harm risk are appropriate.
Touch may escalate agitation, and denying voices dismisses the client’s reality.

Extract:

The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.


Question 4 of 5

For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.

RationaleApplicableNot Applicable
The client is unconscious
The client is under the age of 70
The client's toxicology report reveals no illegal substances
The client does not have a living will documented in the medical record

Correct Answer: A,D

Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.

Extract:

The nurse is caring for a 23-year-old client. Nurses' Notes Vital Signs Medication Administration Record
Inpatient Unit Admission:
The client was found alone in a public park shouting at people who were not present. The client told the staff, "There's nothing wrong with me. It's just the effects of the microchip that was implanted in my head." The client is not oriented to place or time. Day 7: The client has developed confusion, fever, and diaphoresis. Speech is slurred Muscular rigidity is observed in all extremities. Deep tendon reflexes are 2+; no clonus is noted


Question 5 of 5

The nurse recognizes that the client is most likely experiencing which is a complication of

Correct Answer: C,F

Rationale: Neuroleptic malignant syndrome is a complication of antipsychotics like olanzapine , presenting with fever, rigidity, and confusion.

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