Reduction of Risk Potential NCLEX PN Questions

Extract:

Question 1 of 5

While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?

Correct Answer: C

Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Question 2 of 5

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that

A. a referral is needed to the psychiatrist who is to provide the client with answers B. the client has a right to know about the prescribed medications C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Correct Answer: B

Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.

Question 3 of 5

A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that

A. such fantasies can gratify unconscious wishes or prepare for anticipated future events B. detaching or dissociating in this way postpones painful feelings C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership D. isolating the feelings in this way reduces conflict within the client and with others

Correct Answer: A

Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.

Question 4 of 5

The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.

A. The client's infusion pump is noted to have a cut in the center of the cord. B. The client's bed is in the high position after a nursing assistant left the room. C. The client's battery-operated CD player does not have an agency inspection tag. D. The client's bed exit alarm is beeping, and another nurse just left the room. E. The client's bedside table is placed in front of the chair where the client is sitting.

Correct Answer: A,B,D

Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.

Question 5 of 5

The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (ALS). Which of these pieces of equipment is the priority for the client to have access to in the home?

A. A wheelchair B. A hospital bed with trapeze C. A communication board D. A suction machine

Correct Answer: C

Rationale: In late-stage ALS, clients often lose the ability to speak due to muscle weakness. A communication board is critical to ensure the client can express needs and maintain communication.

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