Free NCLEX RN Exam
Question 1 of 5.
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
A. The fact is you are an alcoholic or you wouldn't be here.
B. I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.
C. If you can stop drinking when you want to, why don't you stop?
D. It's good that you can stop drinking when you want to.
Explanation: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.
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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