NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
Question 2 of 5
A client with a history of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
Question 3 of 5
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
Question 4 of 5
The nurse is assessing a client with a suspected urinary tract infection. Which of the following symptoms is most likely to be present?
Correct Answer: A
Rationale: Flank pain is a common symptom of a urinary tract infection, especially if it involves the kidneys.
Question 5 of 5
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.