Mock NCLEX RN Exam
Question 1 of 5.
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
A. I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness.'
B. Just don't pay attention to the voices. They'll go away after some medication.'
C. You can't leave here. This unit is locked and the doctor has not ordered your discharge.'
D. We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'
Explanation: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
Question 2 of 5.
The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
A. Mashed potatoes
B. Smooth peanut butter
C. Fried fish
D. Rice
Explanation: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.
Question 3 of 5.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
C. The client will be more compliant with a medication that allows some feelings of hypomania.
D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Explanation: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.
Question 4 of 5.
Which one of the following situations represents a maturational crisis for the family?
A. A four-year-old entering nursery school
B. Development of preeclampsia during pregnancy
C. Loss of employment and health benefits
D. Hospitalization of a grandfather with a stroke
Explanation: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
Question 5 of 5.
The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
A. A multigravida with diabetes mellitus
B. A primigravida with preeclampsia
C. A multigravida with preterm labor
D. A primigravida with hyperemesis gravidarum
Explanation: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.