a client reports that someone is in the room and trying to kill him the nurses best response is
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Nursing Elites

NCLEX-PN

2024 Nclex Questions

1. A client reports that someone is in the room and trying to kill him. The nurse's best response is:

Correct answer: B

Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner. Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.

2. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?

Correct answer: D

Rationale: A culture for gonorrhea is taken from the genital secretions as gonorrhea primarily affects the genital area. The culture is incubated in a warm environment to promote the growth of Neisseria gonorrhoeae, the bacterium causing gonorrhea. Genital secretions provide a direct sample from the site of infection, increasing the accuracy of diagnosis. Choices A, B, and C are incorrect as they are not suitable specimens for diagnosing gonorrhea. Blood cultures are used to detect bloodstream infections, nasopharyngeal secretions are collected for respiratory infections, and stool cultures are done to identify gastrointestinal infections, none of which are related to gonorrhea.

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. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

Correct answer: B

Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.

5. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?

Correct answer: B

Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.

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