NCLEX-PN
Physiological Adaptation NCLEX Questions
Extract:
Question 1 of 5
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
Correct Answer: D
Rationale: If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one - that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.
Question 2 of 5
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
Correct Answer: C
Rationale: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.
Question 3 of 5
When planning intervention for a client during a crisis, which of the following outcomes is most appropriate?
Correct Answer: D
Rationale: The primary goal of crisis intervention is to relieve the symptoms of anxiety and foster constructive coping. Previous psychological issues might recur during crisis, but the focus is on short-term resolution of the current problem. At the end, the nurse credits a client for positive changes and helps him or her understand what was learned. This allows the client to use the learned coping mechanisms when new problems arise.
Question 4 of 5
The highest incident of child abuse occurs in children in which age group?
Correct Answer: A
Rationale: Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). Girls are slightly more likely to be victims than boys.
Question 5 of 5
A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
Correct Answer: D
Rationale: Hallway discussions should not occur, because you do not know who is listening, even though it may be a professional discussion.