NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: C

Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice
A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice
B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice
D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.

Correct Answer: C

Rationale: The correct action to help prevent a fire in a healthcare setting is to notify visitors or post signs indicating that oxygen is in use in certain areas. Oxygen is a combustible material, and awareness of its presence is crucial to prevent fire hazards. By informing all individuals in the facility about the use of oxygen through clear signs or notifications, the risk of improper use and potential fire accidents can be minimized.


Choice A is incorrect because using an adaptor when plugging in client equipment is not directly related to fire prevention.
Choice B is also incorrect as marking faulty equipment and using it until inspection does not directly address fire prevention.
Choice D is not a recommended action for fire prevention; storing extra equipment with supplies does not address the specific fire risk associated with oxygen use.

Correct Answer: A

Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.

Correct Answer: D

Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice
C) or using a foam swab only on the tongue (choice
B) may not provide the comprehensive mouth care necessary for patients in a coma.

Correct Answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis.

Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.