NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: D

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

Correct Answer: B

Rationale: When the physician asks for the patient to be placed with their dorsal side facing the exam table, it means the patient should be lying on their back. This position is known as the supine position, where the patient's back is on the table, facing up towards the ceiling.
Choice A, 'The patient is lying prone,' is incorrect as the prone position is when the patient is lying face down.
Choice C, 'The patient is lying in the recovery position,' is incorrect as the recovery position is a lateral position typically used in first aid.
Choice D, 'The patient is lying on his stomach,' is incorrect as it describes the prone position, not the supine position as required in this scenario.

Correct Answer: A

Rationale: The correct answer is the Hypothalamus. The hypothalamus is responsible for regulating body temperature, ensuring it stays within a narrow range. Moreover, the hypothalamus controls various essential bodily functions, such as hunger, thirst, and circadian rhythms.

Choices B, C, and D are incorrect because the Pituitary Gland primarily produces and releases hormones, the Pons is involved in functions like sleep, respiration, and bladder control, and the Medulla Oblongata controls vital functions like breathing and heart rate, but not body temperature regulation.

Correct Answer: A

Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time.

Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition.

Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation.

Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.

Correct Answer: B

Rationale: The correct answer is that the weight gain may be due to the urinary drainage bag not being emptied today, while it was emptied on previous days. This scenario is common and can lead to an increase in weight that is not related to food intake.
Choice A is incorrect because assuming visitors are sneaking junk food is speculative and not based on facts.
Choice C is incorrect as there is no evidence to suggest the scale is broken.
Choice D is incorrect because any unexplained weight gain should be investigated further, even if it seems insignificant at first.