a 57 year old woman is recently widowed she states i will never be able to learn how to manage the finances my husband did all of that select the nurs
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Nursing Elites

NCLEX-PN

PN Nclex Questions 2024

1. A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.

Correct answer: C

Rationale: The nurse can raise the client's self-esteem by acknowledging the client's feelings and providing positive reinforcement. Choice C shows empathy and support by recognizing the client's strength and potential to learn. This response encourages the client to believe in her abilities and instills confidence. Choices A and B may come across as judgmental or critical, which can further lower the client's self-esteem. Choice D, while offering a solution, does not address the client's emotional needs or provide direct reassurance about her capabilities.

2. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?

Correct answer: B

Rationale: The correct answer is 'Mania.' A client with a serum sodium level of 170 meq/L has hypernatremia, which can lead to manic behavior. Hypernatremia is associated with irritability, restlessness, confusion, and in severe cases, manic symptoms. Choices A, C, and D (Anger, Depression, Psychosis) are not typically associated with hypernatremia and are, therefore, incorrect in this context.

3. Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?

Correct answer: B

Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.

4. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?

Correct answer: A

Rationale: During suctioning, a vagal response can be triggered leading to bradycardia. It is crucial for the nurse to monitor for this potential dysrhythmia. Tachycardia (Choice B) is less likely during suctioning and is not the priority. Premature ventricular beats (Choice C) and heart block (Choice D) can occur but are less common compared to bradycardia in this situation.

5. A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?

Correct answer: D

Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.

Similar Questions

The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?
A corporate executive works 60-80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?
The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?

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