NCLEX RN Exam Review Answers

Extract:

Question 1 of 5

Which of the following is an example of restorative care?

Correct Answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function.

Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (
Choice
A) is an example of educative care, placing an allergy wristband (
Choice
C) is a safety measure, and contacting a client's family to update them on surgery (
Choice
D) is related to communication and support, not restorative care.

Question 2 of 5

The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?

A. All elderly individuals experience depression occasionally.'' B. I'm relieved that I will improve within 2 or 3 days.'' C. I never realized depression could occur without a specific cause.'' D. Reducing stress in my life will alleviate the depression.''

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.

Question 3 of 5

A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?

A. Encourage the client to participate in group therapy on the unit. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

Correct Answer: B

Rationale: When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.

Question 4 of 5

A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

A. Stop the interview at this point and resume later when the client is better able to concentrate B. Ask the client, 'Are you seeing something on the ceiling?' C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.' D. Continue the interview without commenting on the client's behavior

Correct Answer: B

Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury.

Choices A, C, and D are incorrect. Stopping the interview (choice
A) may not address the immediate concern of the hallucination. Providing false reassurance (choice
C) or ignoring the behavior (choice
D) does not actively address the client's altered perception of reality.

Question 5 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:

A. To tell the client this is not true; that we all have a purpose in life. B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings. C. To reassure the client that you know how the client is feeling and that things will get better. D. To identify recent behaviors or accomplishments that demonstrate skill ability.

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.

NCLEX RN Exam Review Answers - Nurselytic

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