NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
Correct Answer: A,B,C
Rationale:
To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
Question 2 of 5
You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients?
Correct Answer: C
Rationale: Cognitive behavioral psychotherapy (CBT) is the most effective treatment for phobias, as it combines cognitive restructuring with behavioral techniques like exposure therapy to address irrational fears.
Question 3 of 5
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instruction in the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:
Correct Answer: A
Rationale: Teaching the client to monitor their radial pulse ensures they can detect irregularities or bradycardia, a critical aspect of managing digoxin therapy.
Question 4 of 5
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.
Question 5 of 5
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.