NCLEX-RN
NCLEX RN Exam Review Answers Questions
Extract:
Question 1 of 5
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement.
Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement.
Choice B, remaining silent, may lead the client to feel unheard or unsupported.
Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client.
Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
Question 2 of 5
A client on lithium has diarrhea and vomiting. What should the nurse do first?
Correct Answer: D
Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.
Question 3 of 5
Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?
Correct Answer: B
Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust.
Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance.
Choice C delays addressing Gio's concerns and may not provide immediate support.
Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.
Question 4 of 5
Which of the following clients have barriers to accessing healthcare?
Correct Answer: D
Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments.
Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
Question 5 of 5
The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?
Correct Answer: C
Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching.
Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding.
Choice B is incorrect as it reflects a misconception about the quick resolution of depression.
Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.