NCLEX RN Exam Review Answers - Nurselytic

Correct Answer: A

Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.

Correct Answer: C

Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement.
Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement.
Choice B, remaining silent, may lead the client to feel unheard or unsupported.
Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client.
Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.

Correct Answer: A

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age
The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight.
As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

Correct Answer: A

Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.

Correct Answer: D

Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice
A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice
B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice
C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.