NCLEX-PN
NCLEX Client Needs Physiologic Adaptation Questions
Extract:
Question 1 of 5
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
Question 2 of 5
A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
Correct Answer: B
Rationale: The nurse's role is to help the client deal with the stress caused by the remembered abuse.
Question 3 of 5
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
Question 4 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: There is a correlation between vague symptoms, such as abdominal pain, and battered syndrome. The astute clinician should question any woman who presents with suspicious symptoms such as these. Rarely are women offended by a properly worded question, such as, 'Do you feel safe in your present relationship?' Studies show an increase in case finding when such questions are asked. It is not mandatory that all women are assessed for violence, but it is prudent that all persons new to a clinician be assessed by at least the one question noted previously. Castigating or shaming the physician typically does not improve client outcomes and might make for a difficult working environment for the nurse. Tactless comments, like the one in
Choice 4, are not collegial and should be avoided.
Question 5 of 5
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
Correct Answer: B
Rationale: Crying reflects regression, a return to a less mature emotional response to disappointment. Conversion involves physical symptoms, introjection is identification with another, and rationalization is justifying feelings.