NCLEX-RN Exam

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Question 1 of 5.

The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?

A. Approach the client on a continuum of least restrictive care.

B. Challenge client's behavior immediately with steps to prevent injury to self or others.

C. Leave the aggressive client to himself or herself, and take other clients away.

D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.

Explanation: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.

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.