NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:

Correct Answer: A

Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.

Question 2 of 5

A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?

Correct Answer: D

Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (
A) is unnecessary, high-fiber foods like nuts (
B) may cause blockages, and limiting fluids (
C) risks dehydration.

Question 3 of 5

The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?

Correct Answer: A

Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.

Question 4 of 5

The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:

Correct Answer: C

Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.

Question 5 of 5

A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

Correct Answer: C

Rationale: The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately.

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