NCLEX EXAM PREP TIMBYS 2026
COMPREHENSIVE QUESTIONS SOLUTIONS
GRADED A PLUS SAFE PATIENT CARE
PRACTICE SHEET
◉ A minister approaches a nurse caring for a client who is a member
of the minister's congregation. The minister inquires as to whether
the member has been made aware of his/her diagnosis. Which of the
following would be the best response by the nurse?
Answer: "I understand your concern, but have you asked the client?"
Explanation:
The nurse must maintain confidentiality. The minister may mean
well but is trying to gather information that is confidential. The
nurse should acknowledge the minister's concern and then suggest
asking the client about the reason for hospitalization. This allows the
client to share with the minister whatever information the client
wants to disclose. The other options are not correct because they do
not protect the client's privacy. Telling the minister that it is not
his/her business is not a decision the nurse should be making
without discussing the situation with the client.
◉ A client experienced a right frontal stroke that left him with short-
term memory loss and lack of impulse control. The nurse caring for
,the client on the previous shift identified him at high risk for falls.
While making rounds to begin the shift, a nurse notices the client
lying on the floor. The nurse assesses the client and notes no
injuries. How should the nurse follow up this incident?
Answer: Notify the physician, then document the location of the fall,
physician notification, any injury, necessary follow-up, and any
changes in the care plan needed as a result of the fall.
Explanation:
The nurse should notify the physician, then document the facts
related to the fall, such as the location of the fall, physician
notification, injury if any, necessary follow-up, and any changes in
the care plan that occurred as a result of the fall. The nurse shouldn't
include any information that places blame on other health care
members. The fall must be reported even if the client doesn't suffer
an injury.
◉ A client seeks medical attention for dyspnea, chest pain, syncope,
fatigue, and palpitations. A thorough physical examination reveals an
apical systolic thrill and heave, along with a fourth heart sound (S4)
and a systolic murmur. Diagnostic tests reveal that the client has
hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may
be appropriate?
Answer: Decreased cardiac output
Explanation:
,Decreased cardiac output is an appropriate nursing diagnosis for a
client with HCM because the hypertrophied cardiac muscle
decreases the effectiveness of the heart's contraction, decreasing
cardiac output. Heart failure may complicate HCM, causing fluid
volume excess; therefore, the nursing diagnosis of Risk for deficient
fluid volume isn't applicable. Ineffective thermoregulation and Risk
for peripheral neurovascular dysfunction are inappropriate because
HCM doesn't cause these problems.
◉ On admission to the psychiatric unit, a client with major
depression reports that a family member is physically abusive and
requests that the nurse not release any personal information to
anyone. When the allegedly abusive family member calls the unit
and demands information about the client's treatment, what is the
nurse's best response?
Answer: "To protect clients' confidentiality, I can't give any
information, including whether your relative is receiving treatment
here."
Explanation:
The client has the right to confidential treatment, and the nurse has
a duty to protect his confidentiality. Stating that to protect clients'
confidentiality no information will be given is a diplomatic response.
Although simply telling the caller that information can't be released
protects the client's confidentiality, this response isn't as diplomatic
as the first response. Stating that the client isn't accepting phone
calls or that the client didn't sign an information form with the
, caller's name on it divulges the client's whereabouts and status,
violating confidentiality.
◉ A health care provider is legally and ethically required to disclose
certain information. Which confidential information should the
nurse disclose?
Answer: A taxi driver's diagnosis of an uncontrolled seizure disorder
to his licensing agency
Explanation:
The health care provider may lawfully disclose confidential
information about a client when the welfare of others is at stake. The
health care provider is required to inform the Department of Motor
Vehicles that the taxi driver has an uncontrolled seizure disorder
because it's in the best interest of the public's and client's safety.
Confidentiality of HIV testing is required. Disclosing a client's cancer
diagnosis to a significant other or pregnancy to a legally separated
partner do not affect the welfare of person.
◉ The nurse is inspecting the client's abdomen (see the
accompanying image). The nurse should document that the client's
abdomen:
Answer: is flat and symmetrical.
Explanation:
COMPREHENSIVE QUESTIONS SOLUTIONS
GRADED A PLUS SAFE PATIENT CARE
PRACTICE SHEET
◉ A minister approaches a nurse caring for a client who is a member
of the minister's congregation. The minister inquires as to whether
the member has been made aware of his/her diagnosis. Which of the
following would be the best response by the nurse?
Answer: "I understand your concern, but have you asked the client?"
Explanation:
The nurse must maintain confidentiality. The minister may mean
well but is trying to gather information that is confidential. The
nurse should acknowledge the minister's concern and then suggest
asking the client about the reason for hospitalization. This allows the
client to share with the minister whatever information the client
wants to disclose. The other options are not correct because they do
not protect the client's privacy. Telling the minister that it is not
his/her business is not a decision the nurse should be making
without discussing the situation with the client.
◉ A client experienced a right frontal stroke that left him with short-
term memory loss and lack of impulse control. The nurse caring for
,the client on the previous shift identified him at high risk for falls.
While making rounds to begin the shift, a nurse notices the client
lying on the floor. The nurse assesses the client and notes no
injuries. How should the nurse follow up this incident?
Answer: Notify the physician, then document the location of the fall,
physician notification, any injury, necessary follow-up, and any
changes in the care plan needed as a result of the fall.
Explanation:
The nurse should notify the physician, then document the facts
related to the fall, such as the location of the fall, physician
notification, injury if any, necessary follow-up, and any changes in
the care plan that occurred as a result of the fall. The nurse shouldn't
include any information that places blame on other health care
members. The fall must be reported even if the client doesn't suffer
an injury.
◉ A client seeks medical attention for dyspnea, chest pain, syncope,
fatigue, and palpitations. A thorough physical examination reveals an
apical systolic thrill and heave, along with a fourth heart sound (S4)
and a systolic murmur. Diagnostic tests reveal that the client has
hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may
be appropriate?
Answer: Decreased cardiac output
Explanation:
,Decreased cardiac output is an appropriate nursing diagnosis for a
client with HCM because the hypertrophied cardiac muscle
decreases the effectiveness of the heart's contraction, decreasing
cardiac output. Heart failure may complicate HCM, causing fluid
volume excess; therefore, the nursing diagnosis of Risk for deficient
fluid volume isn't applicable. Ineffective thermoregulation and Risk
for peripheral neurovascular dysfunction are inappropriate because
HCM doesn't cause these problems.
◉ On admission to the psychiatric unit, a client with major
depression reports that a family member is physically abusive and
requests that the nurse not release any personal information to
anyone. When the allegedly abusive family member calls the unit
and demands information about the client's treatment, what is the
nurse's best response?
Answer: "To protect clients' confidentiality, I can't give any
information, including whether your relative is receiving treatment
here."
Explanation:
The client has the right to confidential treatment, and the nurse has
a duty to protect his confidentiality. Stating that to protect clients'
confidentiality no information will be given is a diplomatic response.
Although simply telling the caller that information can't be released
protects the client's confidentiality, this response isn't as diplomatic
as the first response. Stating that the client isn't accepting phone
calls or that the client didn't sign an information form with the
, caller's name on it divulges the client's whereabouts and status,
violating confidentiality.
◉ A health care provider is legally and ethically required to disclose
certain information. Which confidential information should the
nurse disclose?
Answer: A taxi driver's diagnosis of an uncontrolled seizure disorder
to his licensing agency
Explanation:
The health care provider may lawfully disclose confidential
information about a client when the welfare of others is at stake. The
health care provider is required to inform the Department of Motor
Vehicles that the taxi driver has an uncontrolled seizure disorder
because it's in the best interest of the public's and client's safety.
Confidentiality of HIV testing is required. Disclosing a client's cancer
diagnosis to a significant other or pregnancy to a legally separated
partner do not affect the welfare of person.
◉ The nurse is inspecting the client's abdomen (see the
accompanying image). The nurse should document that the client's
abdomen:
Answer: is flat and symmetrical.
Explanation:
