NCLEX-PN
Nclex Practice Questions 2024 Questions
Extract:
Question 1 of 5
A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:
Correct Answer: A
Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently.
Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.
Question 2 of 5
What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
Correct Answer: D
Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice
A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice
B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice
C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
Question 3 of 5
A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
Correct Answer: A
Rationale: The correct answer is, "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."? There is a well-documented correlation between vague symptoms like abdominal pain and battered woman syndrome. It is crucial for healthcare providers to inquire about potential domestic violence when presented with such symptoms.
Choice B is incorrect as studies show that women are not generally offended by appropriately phrased questions about their safety in relationships. While it is not mandatory to question all women about domestic violence, it is advisable to at least ask a screening question regarding safety.
Choice D is inappropriate as it uses a shaming tactic, which is not constructive and may create a hostile work environment. It's important for healthcare professionals to approach sensitive topics like domestic violence with empathy and professionalism.
Question 4 of 5
The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
Correct Answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
Question 5 of 5
To ensure safety while administering a nitroglycerine patch, what should the nurse do?
Correct Answer: A
Rationale:
To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.