NCLEX Sample Test 1 with 100% correct solutions 2024

The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1. A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness. 2. A patient indicates an intent to kill himself and says he has access to a gun. 3. A patient had a miscarriage last evening and is experiencing anger and resentment. 4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety. correct answersStrategy: "FIRST" indicates priority. 1) need to assess physical needs and examine patient; second patient to see 2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat 3) allow client to verbalize feelings 4) allow client to verbalize feelings The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions? 1. Time the frequency of the contractions. 2. Assess the type of vaginal discharge. 3. Monitor the strength of the contractions. 4. Observe the perineum. correct answersStrategy: Assess before implementing. 1) priority is assessing if baby is crowning 2) priority is assessing if baby is crowning 3) labor is not the priority; nurse should determine if the birth is imminent 4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant's head; apply slight pressure to control delivery