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  1. Home
  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 81

A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

Correct Answer: A
Explanation
(A) This response validates the client's experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client's verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. (D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
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Question 82

Which nursing implication is appropriate for a client undergoing a paracentesis?

Correct Answer: A
Explanation/Reference:
Explanation:
(A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure.
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Question 83

A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?

Correct Answer: D
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high-calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.
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Question 84

A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms.
It is important for the father to realize certain neurological patterns that characterize the newborn:

Correct Answer: C
Explanation
(A) Term neonates are predominantly in a flexed position with strong active muscle tone that increases.
Newborns are slightly hypertonic. (B) Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. (C) Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. (D) Asymmetrical movements of the extremities are indicative of neurological dysfunction.
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Question 85

After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:

Correct Answer: A
Explanation/Reference:
Explanation:
(A) When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. (B) Improvement in behavior is not indicative of an exacerbation of depressive symptoms. (C) Thedepressed client has a tendency for self-violence, not violence toward others. (D) Depressive behavior is not always accompanied by psychotic behavior.
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