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

Questions 85

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NCLEX PN Practice Test with NGN Questions

Extract:

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

Nurses' Notes
Inpatient - Mental Health Unit
2100:
Client appears anxious and withdrawn, and states, "I am afraid to sleep at night because I get nightmares about my sibling." The client would not elaborate on the content of the nightmares.


Question 1 of 5

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

Correct Answer: B,C,E

Rationale: Appropriate interventions include identifying support systems (
B), directly assessing for self-harm (
C), and using relaxation techniques (E). Providing privacy during flashbacks (
A) may increase distress, assessing ADLs (
D) is less urgent, and avoiding discussion of the trauma (F) may hinder therapeutic progress.

Question 2 of 5

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

Potential Intervention Appropriate Not Appropriate
Provide the client privacy during flashbacks
Help the client identify available support systems
Directly ask if the client is having thoughts of self-harm
Determine the client's ability to perform activities of daily living
Reinforce the use of progressive muscle relaxation for anxiety
Avoid discussion of the traumatic event when speaking to the client

Correct Answer: B,C,E

Rationale: Appropriate interventions include identifying support systems (
B), directly assessing for self-harm (
C), and using relaxation techniques (E). Providing privacy during flashbacks (
A) may increase distress, assessing ADLs (
D) is less urgent, and avoiding discussion of the trauma (F) may hinder therapeutic progress.

Extract:

The nurse is caring for a 12-month-old male client.
History and Physical
Body System
General
The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day; the parents report that the client seems more tired and less playful; both parents and the sister are healthy, but a maternal uncle died at age 7 after mild head trauma.

Integumentary
Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising

Eye, Ear, Nose, and Throat (EENT)
The parents report that the client's gums have been bleeding when chewing on crackers

Pulmonary
Vital signs: RR 38, SpO 100% on room air, upper respiratory infection 3 weeks ago that completely resolved after 4 days.

Cardiovascular
Vital signs: T 98.7 F (37.1 C), P 136

Musculoskeletal
Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities; the parents state the child has recently started learning to walk by holding onto furniture and sometimes falls

Genitourinary
The parents state that urine output has been normal; urine is clear and pale yellow; the penis is uncircumcised

Psychosocial
The client is cooperative during examination; the client appears appropriately dressed for the season and weather; the mother says the child has no interest in toilet-training.

Laboratory Results.
Laboratory Test and Reference Range
Hematology.

Hematocrit
1-6 years: 39% (0.39)
30%-40%:
(0.30-0.40)

WBC
<_ 2 years: 8000/mm3 (8.0 × 10%/L)
6200-17,000/mm3
(6.2-17.0 × 10°/L)
Platelets
150,000-400,000/mm3: 163,000/mm3 (163 × 10°/L)
(150-400 × 10°/L)


aPTT (Activated partial thromboplastin time)
30-40 sec: 60 sec

PT
11-12.5 sec: 12 sec

Factor VIII
55%-145%: 6%

Factor IX
60%-140%: 100%


Question 3 of 5

Which of the following precautions should be included to encourage a safe environment for age-appropriate play? Select all that apply.

Correct Answer: A,B,C,E

Rationale: A: Included - Padding furniture corners reduces injury risk. B: Included - A medical alert bracelet ensures others are aware of the child's hemophilia. C: Included - Ice packs help manage joint bleeding. E: Included - Rugs and play pads cushion falls. D: Not included - Restricting play is not age-appropriate and may hinder development.

Question 4 of 5

The client is most likely experiencing......... due to.......

Correct Answer: A,E

Rationale: The client is most likely experiencing hemophilia due to deficiency of clotting factors. Laboratory results show low Factor VIII (6%) and prolonged aPTT (60 sec), consistent with hemophilia A. The family history and symptoms like bruising and joint swelling further support this diagnosis.

Extract:

The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).


Question 5 of 5

The client is at risk for which of the following complications? Select all that apply.

Correct Answer: A,C,D,E

Rationale: The client is at risk for atelectasis (
A) due to immobility, constipation (
C) from reduced activity and medications, deep venous thrombosis (
D) due to immobility, and osteomyelitis (E) from pin site infection.

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