NCLEX RN Practice Test

Acknowledging a client’s emotional response fosters trust and demonstrates empathy, which is key to promoting positive coping strategies. Encouraging the client to express their concerns helps identify specific fears or misconceptions that can be addressed during the teaching session. This approach prioritizes understanding the client's perspective and lays the groundwork for effective care planning. Conversely, advising the client to focus on the benefits of their new routine might unintentionally minimize their current emotional struggle. Reassuring statements, such as 'It will get easier,' lack specificity and do not explore the deeper reasons behind the client’s distress. Offering solutions before fully understanding the client's perspective may hinder the therapeutic communication process and might not align with the client's immediate emotional needs.

Nurses are legally and ethically required to report suspected abuse-verification or proof is not required. Reporting promptly to the designated agency (for example, adult protective services or the facility's abuse hotline) initiates an investigation by the proper authorities and helps protect the client. Simply documenting and waiting for additional evidence, confronting the suspected perpetrator, or transferring the client without reporting can delay intervention and place the client at further risk.

The correct answer is to encourage the client to express their feelings about the guilt they’re experiencing. Actively listening and providing a safe space for the client to verbalize their emotions is a key part of therapeutic communication and grief support. Validating feelings helps the client begin to process their grief in a healthy manner. While providing information about grief stages or suggesting distractions may be helpful in later interventions, these responses are not the most effective initial actions when addressing the emotional intensity of guilt. Minimizing their guilt without exploration of their emotions disregards the client’s need for validation and recognition of their feelings.

The correct answer is to honor the client’s advance directive and discuss it with the family member. Advance directives are legal documents that reflect the client’s wishes. Respecting these preferences is paramount in providing ethically sound care. The nurse should use therapeutic communication to educate the family member about the client’s documented choices, ensuring they understand the significance of those decisions. Other options fail to prioritize the client’s autonomy: implementing life-prolonging interventions without consent violates legal and ethical principles, and referring the issue to the healthcare provider without addressing the family’s concerns fails to demonstrate patient advocacy or nurse-patient-family collaboration.

The correct answer is to assess the current clinical status of each assigned client. Gaining an understanding of each client’s condition allows the nurse to identify any emergencies, high-priority needs, or time-sensitive interventions. This step is the foundation of effective care planning, helping to ensure that critical tasks are completed in the appropriate order.

Other options, such as starting documentation, delegating tasks, or focusing on routine medications, may seem helpful but lack the broader assessment needed to establish priorities. For example, administering medications without evaluating clients might miss acute changes in condition, and delegating tasks without understanding workload needs could lead to inappropriate task assignments.

The correct action is to encourage the client to attend the session and explore the reasons for their reluctance. This approach respects the client's autonomy while also using therapeutic communication to understand and address their concerns. Forcing a client to attend therapy by making it mandatory or threatening consequences like a delayed discharge is coercive and can damage the therapeutic relationship. Simply documenting the refusal without further engagement is a passive approach that fails to provide therapeutic support.

The correct answer is educating the client about the risks of substance misuse and offering resources for support. Substance misuse can have severe physical, mental, and social consequences, including dependency, impaired decision-making, and chronic health conditions. Nurses play an essential role in empowering clients with accurate information and access to resources to mitigate these risks. Although addressing peers' influence and consulting therapy are important, substance misuse education is the first step in reducing high-risk behaviors. Other options, like discouraging gathering with friends, do not directly target the issue.

Encouraging consistent hand hygiene is essential for a school-age child because it significantly reduces the risk of infectious diseases, such as colds and gastrointestinal illnesses, which are common in school settings. While advising on proper nutrition and hydration is also important to the child's growth and learning, and discussing bullying prevention is relevant to emotional health, hand hygiene directly supports physical health and aligns closely with the parent's concern for the child's safety and health in this context. Other options, such as teaching traffic safety, relate more broadly to safety but are less closely tied to the immediate concern about the school environment.

Folic acid, a B vitamin, is crucial during pregnancy because it helps form the neural tube and reduces the risk of neural tube defects like spina bifida and anencephaly. Although other nutrients like calcium, iron, and vitamin D are important for overall fetal development, they are not specifically associated with neural tube defect prevention.

Withdrawal from central nervous system depressants such as alcohol produces autonomic hyperactivity (tachycardia, hypertension, diaphoresis), coarse tremor, agitation, and altered sensorium within 6-24 hours of the last intake. These features match the client's presentation. Opioid (heroin) withdrawal causes rhinorrhea, lacrimation, abdominal cramping, and piloerection rather than severe tremors and hypertension. Stimulant (cocaine) intoxication-not withdrawal-causes agitation and tachycardia; cocaine withdrawal is characterized mainly by fatigue and depression. Cannabis withdrawal produces irritability and sleep disturbance but not marked tremor or autonomic instability. Therefore, alcohol withdrawal is the most likely etiology.

The correct response involves educating the family about the purpose of pain management in hospice care, specifically that the primary goal is to improve the patient's comfort and quality of life, not to hasten death. It is important to reassure the family that pain medications, such as opioids, are carefully prescribed and administered to address suffering while maintaining the highest possible level of well-being. Incorrect answers either fail to address the family's concerns, provide accurate information, or suggest actions that could compromise the patient's comfort. For example, suggesting discontinuing the medication ignores the patient's suffering, while focusing on other aspects of care dismisses the legitimate concerns raised by the family.

When prioritizing client care, the nurse should focus on addressing the patient with the greatest risk to life or critical bodily functions. This is often referred to as using the ABCs (Airway, Breathing, Circulation) of prioritization. In this case, a client with difficulty breathing presents an immediate threat to life, requiring prompt intervention. While conditions like post-surgery pain or monitoring IV fluids are important, they do not pose the same level of urgency as respiratory distress. Delegating tasks like ambulation assistance is also appropriate, but it is not urgent.

The correct answer focuses on personalized education around modifiable risk factors, highlighting small, achievable dietary adjustments and increased physical activity to promote health maintenance. This approach is rooted in evidence-based strategies to mitigate conditions like hypertension and diabetes. While other options suggest potentially helpful measures, they either fail to address modifiable lifestyle risks directly or are inappropriate for this stage of care. For instance, monitoring vitals such as blood pressure does not actively prevent disease, and recommending medications is premature without first encouraging lifestyle changes.

The correct answer reflects the American Academy of Pediatrics' (AAP) safe sleep guidelines, which emphasize placing infants on their backs for sleep on a firm mattress within a crib without loose bedding. This position significantly reduces the risk of SIDS. Allowing side-lying sleep increases instability, potentially leading to dangerous rollovers. Car seats are not safe sleeping environments because of the risk of positional asphyxia. Loose blankets in the crib can raise the risk of suffocation or overheating, which are factors associated with SIDS.

The nurse should first discuss the fasting tradition with the client and work collaboratively to move medication doses to non-fasting hours (for example, before dawn or after sunset) or obtain orders for longer-acting formulations so therapeutic levels are maintained. This approach respects the client's religious practice and supports medication adherence. Giving medications during the fast disregards the client's beliefs, skipping doses endangers therapeutic effectiveness, and telling the client to abandon the fast violates autonomy and cultural sensitivity.

The correct answer is appropriate because monitoring vital signs is commonly within the scope of practice for assistive personnel (AP), as long as the AP has been trained and the RN provides clear instructions and supervision. Tasks requiring assessment, interpretation, or critical decision-making—such as evaluating incision sites or administering medication—are outside the AP's scope of practice and must be performed by a licensed nurse.

The correct answer emphasizes de-escalation through calm communication and an understanding tone, which can diffuse the situation without escalating the client’s agitation. Giving strict instructions to sit down or stop disruptive behavior in a firm tone may escalate conflict, as it can be perceived as confrontational. Threatening removal is not therapeutic and may further upset the client rather than de-escalate the situation. Lastly, implementing physical measures is reserved for high-risk situations where the client poses an immediate threat and other strategies have been unsuccessful. De-escalating verbally is more appropriate as an initial approach.

The correct answer is to adopt an early intervention to de-escalate the client's agitation in a safe manner. Speaking calmly and acknowledging the client's distress lowers the agitation level and demonstrates empathy, reducing the likelihood of violence. Close observation or additional security measures may be necessary but should follow attempts to de-escalate the situation. Restraining or isolating the client should be a last resort and used only when there is an imminent threat of harm. Focusing solely on observing without action risks escalation, and prematurely involving security can intensify the situation unnecessarily.

The correct answer is identifying who the client feels supported by because understanding the client's perception of their support system is crucial in determining who is actively involved in providing encouragement and assistance. Simply observing visitors or asking about family relations does not provide adequate insight into the perceived emotional and practical support available. Discussing future commitments provides information but does not assess the current state of the support system.

The correct answer emphasizes the importance of reducing environmental hazards to decrease the risk of falls. Removing loose rugs reduces tripping hazards, which is a common cause of falls in older adults. Elevated toilet seats and proper lighting are helpful fall-prevention strategies but may not apply to all living environments and do not address hazards caused specifically by tripping. Non-slip shoes are recommended for walking safety but do not address fall risks that arise from the environment. By focusing on removing a common household risk, the correct answer prioritizes preventative measures supported by evidence-based practice.