NCLEX-RN Exam

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Question 1 of 5.

A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

A. Placing her in seclusion until the behavior is under control

B. Walking up to the client and touching her on the arm to get her attention

C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area

D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit

Explanation: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.

Question 2 of 5.

After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:

A. Hamburger

B. Hot dog

C. Potato salad

D. Baked beans

Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.

Question 3 of 5.

A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:

A. Ineffective family coping related to parental role conflict

B. Care-giver role strain related to chronic situational stress

C. Altered family process related to impaired social interaction

D. Altered parenting related to impaired growth and development

Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.

Question 4 of 5.

A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

A. Helping the client develop a plan for changing his behavior

B. Contracting with him for the time he spends on a task

C. Avoiding a discussion of his annoying behavior because it will only make him worse

D. Encouraging him to set a time schedule and deadlines for himself

Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.

Question 5 of 5.

The nurse has just received the change of shift report. Which client should the nurse assess first?

A. A client with a supratentorial tumor awaiting surgery

B. A client admitted with a suspected subdural hematoma

C. A client recently diagnosed with akinetic seizures

D. A client transferring to the neuro rehabilitation unit

Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.