NCLEX RN Practice Test
Question 1 of 5.
The nurse is caring for a client who suffers from post-traumatic stress disorder (PTSD) following the loss of her husband and children in an automobile accident. Which interventions by the nurse are appropriate for this client? Select all that apply.
A. assist the client to develop adequate coping techniques
B. encourage the client to try different relaxation techniques
C. listen to the client in a supportive and nonjudgmental manner
D. allow the client a safe and secure environment to express her feelings
E. encourage the client to avoid going out in public until she has worked through all the stages of grief
Explanation: Appropriate PTSD interventions include teaching coping (A), relaxation techniques (B), supportive listening (C), and providing a safe environment (D). Avoiding public interaction (E) may worsen isolation.
Question 2 of 5.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
A. Take the client to the dining room with 1:1 supervision.
B. Inform the client he may go to the dining room when he controls his behavior.
C. Hold the meal until the client is able to come out of seclusion.
D. Serve the meal to the client in the seclusion room.
Explanation: should eat at regular time; remain in the seclusion room for client’s safety
Question 3 of 5.
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
A. Sit up for at least 30 minutes after eating.
B. Avoid fluids between meals.
C. Increase the intake of high-carbohydrate foods.
D. Avoid eating large meals that are high in simple sugars and liquids.
Explanation: basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates
Question 4 of 5.
The nurse assesses the development of a three-month-old boy in the well-baby clinic. Which of the following behaviors, if observed by the nurse, would be UNEXPECTED?
A. The boy holds his head erect when sitting on the examination table.
B. The boy tries to grasp a toy just out of reach.
C. The boy turns his head to try to locate a sound.
D. The boy smiles spontaneously when he sees his mother.
Explanation: unexpected until 6 months of age
Question 5 of 5.
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?
A. Unequal and dilated pupils.
B. Decerebrate posturing.
C. Grand mal seizures.
D. Decreased level of consciousness.
Explanation: may be confused and stuporous
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