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

Correct Answer:

Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.

Correct Answer: B,D,E,F

Rationale: This client has findings of chronic hyperglycemia, including polydipsia (increased thirst) and polyuria (increased urination) which may indicate
untreated diabetes mellitus. Recent findings also indicate potential upper respiratory infection, hypovolemia, and an acute abdominal
condition. For this client, the following findings are the priority for follow-up:
• Delayed menstruation (time since last menstruation exceeds typical cycle length) could indicate that the client is pregnant, which
presents a risk for pregnancy-related complications (eg, ruptured ectopic pregnancy) and affects care provided to the client (eg, avoid x-
rays and teratogenic medications).
• Decreased level of consciousness (eg, drowsiness, disorientation) places the client at increased risk for injury and aspiration and
may indicate impaired brain perfusion. This may be due to hypotension or hyperglycemia-induced cerebral edema.
• Hypotension causes impaired organ perfusion that could be life threatening without immediate intervention.
• Tachycardia occurs to compensate for hypotension or can be the cause of hypotension and requires prompt attention to prevent
cardiovascular collapse.
• Tachypnea is concerning, particularly when associated with rapid, deep respirations (ie, Kussmaul breathing), because it may indicate a
compensatory response to an underlying metabolic acidosis (eg, ketoacidosis, hypotension-induced lactic acidosis).
• Severe hyperglycemia may indicate diabetic ketoacidosis (DK
A), a life-threatening complication of diabetes mellitus. In addition,
hyperglycemia has a diuretic effect leading to fluid loss that worsens cardiovascular compromise.

Correct Answer: A,C,D,F,G

Rationale: A client with hematemesis and black stools is most likely experiencing an acute gastrointestinal (GI) bleed. GI bleeding is a
life-threatening condition that can lead to hemorrhagic shock without immediate intervention. The nurse should immediately
follow up on:
• Chronic NSAID use (eg, ibuprofen), a common cause of drug-induced upper GI bleeds that must be discontinued.
• Hypotension and tachycardia, manifestations of hypovolemia. Hypotension occurs with decreased cardiac output, and
tachycardia is a compensatory mechanism to promote maximum perfusion to vital organs. Because this client has a
history of hypertension, even borderline low blood pressure is considered abnormal.
• Syncope (ie, passing out), a clinical finding associated with hypovolemia caused by decreased perfusion to the brain.
• Hematemesis (ie, vomiting blood), indicative of bleeding in the upper GI tract (eg, stomach ulcers, esophageal varices).
• Dark/black and/or tarry stools, most often associated with upper GI bleeding; blood becomes partially digested as it
passes through the Gl tract, resulting in the dark color.

Correct Answer: F,B

Rationale: The nurse recognizes that the client is most likely experiencing infective endocarditis (lE) and should prioritize interventions
to prevent systemic emboli.
The client is most likely experiencing IE based on the history of a recent dental procedure and clinical findings of infection (eg,
fever, flu-like symptoms), microemboli (eg, splinter hemorrhages, Janeway lesions), and cardiac murmur. In addition to
microemboli, larger pieces of vegetation can break off the heart valve and embolize to various organs, causing life-threatening
complications (eg, stroke, spleen/kidney infarction).

Correct Answer: B,E

Rationale: Major depressive disorder (MD
D) is characterized by a persistent (duration ≥2 weeks) depression in mood (eg, sadness,
social withdrawal) that interferes with daily life. This client has several clinical manifestations of MDD, including loss of interest
in daily activities, significant change in appetite or weight, persistent feelings of worthlessness, recurrent thoughts of self-harm,
inattention, and fatigue. MDD is a significant risk factor for suicide
Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction,
impaired control, and physical effects (eg, withdrawal). This client's urine drug screen is positive for cocaine and marijuana

Therefore, the nurse should further investigate the client's substance use (eg, amount, frequency, route of administration, date
of last use, perceived benefits, negative consequences)