Free NCLEX RN Exam
Question 1 of 5.
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
A. Must use the least restrictive measure possible to control the behavior
B. Should put the client in seclusion until he promises to behave appropriately
C. Should apply full restraints until the behavior is under control
D. Should allow other clients to observe the acting out so that they can learn from the experience
Explanation: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
Question 2 of 5.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
A. Sodium
B. Potassium
C. Protein
D. Fat
Explanation: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
Question 3 of 5.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
A. Ignore the client's behavior.
B. Exchange the cards for a checker board.
C. Send the other clients to their rooms.
D. Cover the client and walk her to her room.
Explanation: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 4 of 5.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
A. I can help control my weight by switching from sugar to Nutrasweet.
B. I need to resume my old diet before becoming pregnant.
C. I need to eliminate most sources of phenylalanine from my diet.
D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Explanation: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
Question 5 of 5.
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
A. Loss of the myelin sheath in portions of the brain and spinal cord
B. An interruption in the transmission of impulses from nerve endings to muscles
C. Progressive weakness and loss of sensation that begins in the lower extremities
D. Loss of coordination and stiff 'cogwheel' rigidity
Explanation: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
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