3028653747Confidence: Pretty sure Stats Issue with this question?1.A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, “Get out of here!” What is the nurse’s best approach? Correct1Say, “I’ll be back in 15 minutes, and then we can talk.”2Get assistance and give the medication by way of injection.3Explain why it is necessary to comply with the healthcare provider’s order.4Tell the client, “You have to take the medicine that’s been prescribed for you.”Saying, “I’ll be back in 15 minutes, and then we can talk,” allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client’s feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.70%of students nationwide answered this question correctly.View Topics
3204264901Confidence: Nailed itStatsIssue with this question?2.Which is often a source of stress for 5-year-old clients that the nurse should include in the assessment process during the health maintenance visit?1Jealousy2Stubbornness Correct3Procrastination4CompanionshipProcrastination, or a delay completing chores or activities, is a source of stress for 5-year-old clients. Jealousy, stubbornness, and companionship are sources of stress for 3- and 4-year-old preschool-age clients.30%of students nationwide answered this question correctly.View Topics
2982640099Confidence: Nailed itStatsIssue with this question?3.A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, “What can I do to help?” How can the nurse best support the client’s spouse? Correct1Assist the couple to maintain open communication.2Offer the couple a description of the disease process.3Instruct the spouse about the action of the medications.4Meet privately with the spouse to explore personal feelings.Clients and their families need to maintain honest, open interpersonal communication so that concerns can be shared and future problems addressed. Although an understanding of the disease is important, details will not assist the significant other in maintaining an active, caring role. The spouse may want to know about the action of the medications, but it will not help meet the needs of both the spouse and the client. Although the nurse may meet privately with the spouse to explore feelings, this does not address the spouse’s immediate concern.
Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.64%of students nationwide answered this question correctly.View Topics
3042121188Confidence: Nailed itStatsIssue with this question?4.A young client with schizophrenia says, “I’m starting to hear voices.” What is the nurse’s most therapeutic response?1″How do you feel about the voices, and what do they mean to you?”2″You’re the only one hearing the voices. Are you sure you hear them?”3″The health team members will observe your behavior. We won’t leave you alone.” Correct4″I understand that you’re hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?”Acknowledging that client is hearing voices and that the voices are very real to the client validates the presence of the client’s hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self-injury or violence against others. The client’s contact with reality is too tenuous to explore what the voices mean. Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won’t be left alone is condescending and may impair future communication.88%of students nationwide answered this question correctly.View Topics
3204969561Confidence: Pretty sureStatsIssue with this question?5.Which toddler behaviors should the nurse identify as ritualism during the health history portion of the assessment? Select all that apply. Correct1Using the same cup with each meal2Being able to use a spoon efficiently3Eating the same foods as other family members Correct4Refusing to eat if the different foods are touching Correct5Rejecting a meal because it is served in a different bowlToddlers are creatures of habit; behaviors that are indicative of ritualism include using the same cup with each meal, refusing to eat if the different foods are touching, and rejecting a meal because it is served in a different bowl. Being able to use a spoon efficiently is a fine motor skill. Eating the same foods as other family members is a developmental expectation as the child develops through the toddler stage to the preschool stage.39%of students nationwide answered this question correctly.View Topics
A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, “Let me die. I’m no good.” What is the most appropriate response by the nurse?1″Tell me why you did this.” Correct2″You must have been upset to try to take your life.”3″Of course you’re good; we’ll take excellent care of you.”4″You’ve been through a rough time; let me take care of you.”Identifying and showing understanding of the client’s feelings by giving feedback help establish a therapeutic relationship and promote exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the client time to reflect and explore feelings. Saying the client is good and promising to take care of the client negates the client’s feelings and cuts off any further communication of feelings. Saying “Let me take care of you” encourages dependence; it does not permit exploration of feelings.60%of students nationwide answered this question correctly.View Topics
3042088112Confidence: Nailed itStatsIssue with this question?3.The nurse believes that an emotionally disturbed client is ready to begin participating in therapeutic activities. What should the nurse initially suggest? Correct1Drawing pictures with the nurse2Attending a class on medications3Participating on the softball team4Watching television in the dayroomParticipating with one trusted individual gradually diminishes the need for withdrawal. It also allows for nonverbal communication. Attending a class on medications is not an appropriate initial activity, because it requires a higher level of function than the other activities presented require. Participating on the softball team fosters competition, which is not helpful at this time. Watching television in the dayroom will not increase socialization; rather, it will promote withdrawal.72%of students nationwide answered this question correctly.View Topics
2901747888Confidence: Nailed itStatsIssue with this question?4.A client leaves group therapy in the middle of the session. The nurse finds the client obviously upset and crying, and the client tells the nurse that the group’s discussion was too much to tolerate. What is the most therapeutic initial nursing action at this time?1Request kindly but firmly that the client return to the group to work out conflicts. Correct2Suggest that the client accompany the nurse to a quiet place so that they can talk about the situation.3Ask the group leader what happened in the group session and base interventions on this additional information.4Respect the client’s right to decline therapy at this time and report the incident to the rest of the health team members.Asking the client to discuss the situation privately incorporates the principles of starting where the client is and helping the client verbalize feelings; it also facilitates the collection of additional data. The client is not ready to return to the group. Asking the group leader what happened in the group session should be done later, after the more appropriate nursing action is completed. Respecting the client’s right to decline therapy accepts the client’s right not to be forced back into the group; however, direct nursing intervention should be attempted at this time.
Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.77%of students nationwide answered this question correctly.View Topics
3029022662Confidence: Nailed itStatsIssue with this question?5.Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? Correct1Affective instability2Repetitive motor mechanisms3Depersonalization and derealization4Disheveled and unkempt physical appearanceIndividuals with anorexia often display irritability, hostility, and a depressed mood. Repetitive motor mechanisms are associated with autism. Depersonalization and derealization are associated with individuals with schizophrenia. Clients with eating disorders are usually meticulous about dress and physical appearance; a disheveled appearance is associated with dementia or depression.41%of students nationwide answered this question correctly.