Reduction of Risk Potential NCLEX PN Questions

Extract:

Question 1 of 5

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that

Correct Answer: B

Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.

Question 2 of 5

Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control. B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger. C. Restraints are a therapeutic measure designed to positively reinforce client behavior. D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct Answer: B

Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.

Question 3 of 5

The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.

A. The client's infusion pump is noted to have a cut in the center of the cord. B. The client's bed is in the high position after a nursing assistant left the room. C. The client's battery-operated CD player does not have an agency inspection tag. D. The client's bed exit alarm is beeping, and another nurse just left the room. E. The client's bedside table is placed in front of the chair where the client is sitting.

Correct Answer: A,B,D

Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.

Question 4 of 5

The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?

A. Performance on written tests B. Responses to verbal questions C. Completion of a mailed survey D. Reported behavioral changes

Correct Answer: D

Rationale: Reported behavioral changes. If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.

Question 5 of 5

The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.

A. Assess the client's risk for a fall using a rating scale. B. Document that the client is frequently incontinent. C. Ensure an immediate response to the client's call light. D. Educate the client regarding fall prevention strategies. E. Place a note on the door stating, "bathroom every two hours." F. Request that the HCP prescribe placement of a urinary catheter.

Correct Answer: A,C,D

Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.

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