NCLEX-PN
NCLEX Physiological Adaptation Questions
Extract:
Question 1 of 5
A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
Correct Answer: D
Rationale: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment.
Question 2 of 5
Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?
Correct Answer: A
Rationale: VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis.
Question 3 of 5
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
Correct Answer: B
Rationale: Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
Question 4 of 5
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
Correct Answer: C
Rationale: In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.
Question 5 of 5
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.