Nclex Practice Questions 2024 - Nurselytic

Correct Answer: B

Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial.
Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (
Choice
A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (
Choice
D). Obtaining blood gases (
Choice
C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.

Correct Answer: A

Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently.
Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.

Correct Answer: C

Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.

Correct Answer: B

Rationale: The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses.
Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system.
Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming.
Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.

Correct Answer: B

Rationale: The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations.

Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships.
Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence.
Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.