NCLEX-PN
2024 Nclex Questions Questions
Extract:
Question 1 of 5
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
Correct Answer: C
Rationale: Given the history of childhood sexual abuse and the presenting symptoms of difficulty concentrating, insomnia, and nightmares, the nurse should assess the client for post-traumatic stress disorder (PTS
D). Childhood sexual abuse is strongly associated with adult-onset depression and an increased risk for PTSD. Individuals with PTSD may exhibit re-experiencing symptoms such as flashbacks, nightmares, and heightened reactions to trauma triggers. They may also display emotional numbing, avoidance behaviors, and increased arousal symptoms like difficulty sleeping and hypervigilance. Generalized anxiety disorder (
Choice
A) is characterized by excessive worry and anxiety about various events or activities, not necessarily tied to a specific trauma. Schizophrenia (
Choice
B) is a severe mental disorder characterized by distortions in thinking, perception, emotions, and behavior, unrelated to the traumatic event described. Bipolar disorder (
Choice
D) involves mood swings between depressive and manic episodes, and its symptoms differ from those typically seen in PTSD.
Question 2 of 5
Which of the following factors can impact an individual's ability to give informed consent?
Correct Answer: C
Rationale: Pain medications might alter alertness, thought processes, and reactions, potentially impacting an individual's ability to give informed consent. It is recommended to approach a client for consent at least 4 hours after the last dose of pain medicine to minimize any influence.
Choices A, B, and D are incorrect. While IQ and educational level may affect how information is presented during the discussion process, they do not directly impact informed-consent decision-making. Financial status is also not a direct factor in an individual's ability to provide informed consent, unlike pain medications which can directly affect cognitive functions and decision-making abilities.
Question 3 of 5
When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:
Correct Answer: A
Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock.
Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock.
Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock.
Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.
Question 4 of 5
Referral for client education in the community can be accomplished through all of the following except:
Correct Answer: D
Rationale: Client education should be conducted by individuals with acknowledged expertise in the subject area and appropriate credentials to support their activities within the healthcare community.
Choices A, B, and C involve reputable entities or professionals who can provide accurate and reliable client education. The American Heart Association, parish nurses, and home health care agencies are recognized for their healthcare-related knowledge and qualifications. However, unlicensed massage therapists lack the necessary qualifications and expertise to deliver appropriate healthcare-related education, making them unsuitable for referrals when it comes to client education in the community.
Question 5 of 5
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
Correct Answer: D
Rationale: Cyclophosphamide (Cytoxan) can cause hemorrhagic cystitis, a condition characterized by inflammation of the bladder wall leading to bleeding.
To prevent this complication, the client should drink at least eight glasses of water a day. Walking to prevent calcium loss (choice
A) and increasing fiber intake (choice
B) are not directly related to the side effects of Cytoxan, making them unnecessary instructions in this case. While nausea is a common side effect of chemotherapy, the immediate reporting of nausea to the doctor (choice
C) is important but not specifically related to the use of Cytoxan in this scenario.