NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following symptoms should the nurse report immediately?
Correct Answer: C
Rationale: Suicidal thoughts are a medical emergency in clients on SSRIs like sertraline. Options A, B, and D are common side effects.
Question 2 of 5
The nurse is caring for clients on the neurology unit.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
Question 3 of 5
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
Question 4 of 5
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Question 5 of 5
A client admitted to the psychiatric unit claims to be the 'Son of God' and insists that he will not be confined by 'mere mortals.' The most likely explanation for the client's delusions is:
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the 'Son of God,' often stem from low self-esteem, compensating with inflated self-perception. Religious conversion, stress, or anxiety are less likely causes.