NCLEX-PN
NCLEX Client Needs Physiologic Adaptation Questions
Extract:
Question 1 of 5
A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
Correct Answer: C
Rationale: The nurse can raise the client's self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client's feelings and praising the client for seeking assistance.
Question 2 of 5
A two-year old has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
Correct Answer: C
Rationale: Separation anxiety can easily occur after six months during hospitalization.
Question 3 of 5
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
Question 4 of 5
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
Correct Answer: B
Rationale: Crying reflects regression, a return to a less mature emotional response to disappointment. Conversion involves physical symptoms, introjection is identification with another, and rationalization is justifying feelings.
Question 5 of 5
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
Correct Answer: B
Rationale: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.