NCLEX questions and Answers with complete solutions

NCLEX questions and Answers with complete solutions A client asks a nurse, "What is health?" Which concept basic to most definitions of health should the nurse consider when answering the client's question? A. A progressive state B. The absence of disease C. Relative to one's value system D. An extreme of the wellness-illness continuum - ANS- Relative to one's value system A client asks for advice regarding a personal problem. Which is the most appropriate response by the nurse? A. Explain that nurses are not permitted to give advice to a client. B. Encourage the client to speak with a family member. C. Ask the client what would be the best thing to do. D. Offer an opinion after listening to the client - ANS- Ask the client what would be the best thing to do A client asks the nurse why cold compress were prescribes to treat a recent muscle sprain. Which is the reason why old is effective in reducing the discomfort associated with a local inflammatory response that the nurse should include when answering the client's question? A. Anesthetizes nerve endings and causes vasoconstriction B. Stimulates nerve endings and causes vasoconstriction C. Anesthetizes nerve endings and causes vasodilation D. Stimulates nerve endings and causes vasodilation - ANS- Anesthetizes nerve endings and causes vasoconstriction A client becomes upset whenever anyone mentions an upcoming birthday and does not want to talk about age. Which does this behavior reflect? A. Denial B. Sorrow C. Loneliness D. Suppression - ANS- Suppression A client comes to the emergency department reporting pain, nausea, vomiting, and a low-grade fever. Rovsing's sign is elicited when the primary health-care provider palpates the client's left lower quadrant. Place an X over the site where the client felt an increase in pain. - ANS- Lower left quadrant A client has a history of verbally aggressive behavior. One afternoon the client starts to shout at another client in the lounge. Which are appropriate responses by the nurse? Select all that apply. A. "Stop what you are doing." B. "Let's go talk in your room." C. "Sit down until you are calm." D. "Come with me for a walk in the hall." E. "Do not raise your voice in a hospital." - ANS- B, D; "Let's go talk in your room." & "Come with me for a walk in the hall." A client has a nasogastric tube. Which is a daily nursing intervention that contributes to hygeine? A. Instilling the system with one ounce of water B. Replacing the fixation tube C. Suctioning the oral pharynx D. Lubricating the nares - ANS- Lubricating the nares A client has difficulty communicating verbally (expressive aphasia) because of a brain attack (stroke). Which should the nurse do when caring for this client? Select all that apply. A. Anticipate needs to reduce frustration B. Teach the client how to use a picture board C. Encourage the client to elaborate with gestures D. Be patient when the client is attempting to speak E. Ask the client questions that require a yes or no response - ANS- B, C, D A client has difficulty sleeping and the nurse secures a prescription for zolpidem (ambien) extended-release tablets 12.5 mg PO at bedtime. The medication supplied by the pharmacy is 6.25 mg/tablet. How many tablets should the nurse administer? Record your answer using a whole number. - ANS- 2 tablets A client is admitted to the hospital with multiple health problems. Which nursing intervention is least effective in meeting the client's psychosocial needs? A. Addressing the client by name B. Assisting the client with meals C. Identifying achievement of client goals D. Explaining care before it is to be given to the client - ANS- Assisting the client with meals A client is afraid of falling when it is time to get out of bed to a chair. Which is the best action by the nurse to reduce the client's fear? A. Permit the client to set the pace of the transfer B. Transfer the client using a mechanical lift C. Inform the client that a fall will not occur D. Allow the client to decide when to get up - ANS- Permit the client to set the pace of the transfer A client is being discharged to a nursing home. While preparing the discharge summary, the client says, "I feel that nobody cares about me." Which is the nurse's best response? A. "You feel as if nobody cares." B. "We are all concerned about you." C. "It's hard to be angry at your family." D. "Your family doesn't have the skills to care for you." - ANS- "You feel as if nobody cares." A client is confused and disoriented. Which route of communication used by the nurse if most effective in this situation? A. Touch B. Talking C. Writing D. Pictures - ANS- Touch A client is readmitted to the hospital because of complications resulting from nonadherence to the prescribed healthcare regimen. Which should the nurse do first? A. Encourage healthy behaviors B. Develop a trusting relationship C. Use educational aids to reinforce teaching D. Establish why the therapeutic plan is not being followed - ANS- Develop a trusting relationship A client is upset and rambles about an incident that occurred earlier in the week. Which should the nurse do first? A. Ask the client what is wrong B. Identify the client's concerns C. Recognize the client is confused D. Encourage the client to focus on the present - ANS- Identify the client's concerns A client says to the nurse, "lately I've been having a hard time sleeping." Which should the nurse encourage the client to do to promote sleep? Select all that apply. A. Exercise lightly B. Drink a cup of tea C. Eat only light meals D. Review the day's events E. Follow a bedtime routine - ANS- A, E A client tells the nurse, "the doctor just told me I have cancer" and then begins to cry. Which is the best response by the nurse? A. "Try to focus on something else." B. "Sometimes it helps to talk about it." C. "Deep breathing may help you regain control." D. "Tears are good because it gets it out of your system." - ANS- "Sometimes it helps to talk about it." A client verbally communicates with the nurse while exhibiting nonverbal behavior. How should the nurse confirm the meaning of the nonverbal behavior? Select all that apply. A. Look for similarity in meaning between the client's verbal and nonverbal behavior B. Ask family members to help interpret the client's behavior C. Validate inferences by asking the client direct questions D. Recognize that what a client says is most important E. Point out the behavior to the client - ANS- A, C, E A client who had a brain attack (stroke, cerebrovascular accident) 3 days earlier has left-sided hemiparesis. Which should the nurse plan to do when dressing the client? A. Put the client's left sleeve on first B. Encourage the client to dress independently C. Instruct the client to wear clothes with zippers D. Tell the client to get clothes with buttons in the front - ANS- Put the client's left sleeve on first A client who is confused and disoriented is wearing a restraint that was applied following the manufacturer's directions. The client struggles against the restraint. Which does the nurse conclude is the primary reason for this behavior? A. Response to discomfort B. Attempt to gain control C. Effort to manipulate the staff D. Inability to understand what is occurring - ANS- Inability to understand what is occurring A client who is hearing impaired tells the nurse, "I have difficulty hearing what people