NCLEX-PN
2024 Nclex Questions Questions
Extract:
Question 1 of 5
When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
Correct Answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (
Choice
A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (
Choice
C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (
Choice
D) is a temporary solution and does not address the root causes of the behavior.
Question 2 of 5
The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
Correct Answer: C
Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.
Question 3 of 5
When caring for a Native-American family, what does the nurse need to consider?
Correct Answer: C
Rationale: When caring for a Native-American family, it is crucial to acknowledge and respect their cultural beliefs and practices.
Choice A, while relevant, is not as specific as understanding the use of herbs and psychologic treatments in Native American healing practices.
Choice B, though generally true, does not directly impact the nursing care provided.
Choice D, although true, is too broad and does not focus on the specific aspect of treatment practices.
Choice C is the most appropriate answer as it highlights the importance of recognizing and incorporating traditional healing methods into the nursing care plan, promoting culturally sensitive and holistic care.
Question 4 of 5
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
Correct Answer: B
Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner.
Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.
Question 5 of 5
A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization?
Correct Answer: A
Rationale: The correct response acknowledges that hospitalization can lead to a crisis for both patients and their families. By asking if the wife has coped with problems before, it opens up a dialogue about her coping mechanisms and past experiences. This can help the husband understand his wife's current behavior better and provide valuable insights.
Choices B, C, and D do not directly address the potential crisis that hospitalization can cause or inquire about the wife's coping strategies, making them less effective responses.