an 18 year old male patient informs the nurse that he isnt sure if he is homosexual because he is attracted to both genders the nurse establishes a tr
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:

Correct answer: C

Rationale: It is important for the nurse to validate the patient's concerns and provide a supportive environment. By acknowledging that it is normal for young adults to have questions about sexuality, the nurse helps the patient feel understood and accepted. This response encourages further discussion and exploration of the patient's feelings without judgment. Choice A dismisses the patient's concerns and implies that his feelings are not valid. Choice B stigmatizes the patient's feelings by labeling them as abnormal and suggests therapy without proper assessment. Choice D addresses the patient's feelings but lacks the validation and reassurance present in the correct answer, which is essential in building a trusting relationship with the patient.

2. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:

Correct answer: C

Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.

3. A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?

Correct answer: A

Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.

4. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?

Correct answer: C

Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.

5. What is involved in obtaining informed consent?

Correct answer: A

Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability. Therefore, the correct answer is the explanation of the reasons for the procedure.

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