NCLEX-PN Test #7 1 — Questions and Answers
Question 1: A nurse is caring for a client newly diagnosed with breast cancer who states, 'I know they made a mistake with the pathology report. I don't have cancer.' Which nursing response is most therapeutic?
- 'Let's talk about your treatment options so you can feel in control.'
- 'I understand this news is very difficult. What are your thoughts and feelings right now?' (Correct answer)
- 'You need to accept your diagnosis so we can begin treatment.'
- 'I'll arrange for a second pathology opinion if that would help you feel better.'
Correct answer: 'I understand this news is very difficult. What are your thoughts and feelings right now?'
The client is in the denial stage of grief. The most therapeutic response acknowledges the client's feelings and invites open communication. Pushing the client toward acceptance or jumping into treatment planning dismisses emotional needs. Offering a second opinion is not therapeutic communication and may reinforce denial.
Question 2: A nurse is caring for a client with major depressive disorder who states, 'I've been giving away my things and I've said goodbye to my family. I feel at peace now.' How should the nurse interpret this?
- The client has accepted their illness and is improving
- The client is showing warning signs of imminent suicide (Correct answer)
- The client is demonstrating spiritual coping
- The client is experiencing normal grief
Correct answer: The client is showing warning signs of imminent suicide
Giving away possessions, saying goodbyes, and sudden calmness (a 'peaceful' feeling after a period of depression) are critical warning signs of an imminent suicide attempt. The nurse must conduct a direct suicide risk assessment, notify the provider, and implement safety precautions immediately.
Question 3: A nurse is providing care to a client with schizophrenia who says, 'The TV is sending me special messages.' Which response by the nurse is most therapeutic?
- 'I understand why you believe that, but TVs cannot send personal messages.'
- 'What do the messages say?'
- 'I don't see evidence that the TV is sending you messages, but I can see you are distressed.' (Correct answer)
- 'Let's turn off the TV so it doesn't bother you anymore.'
Correct answer: 'I don't see evidence that the TV is sending you messages, but I can see you are distressed.'
The nurse should neither reinforce nor argue with delusions. The therapeutic response acknowledges the client's emotional experience (distress) without validating the delusion. Asking about message content can reinforce the delusion. Dismissing the belief without empathy breaks therapeutic rapport.
Question 4: A nurse is caring for a client with alcohol use disorder who is on day 2 of detoxification. The client suddenly becomes agitated, diaphoretic, and tremulous. Which finding would require the most urgent nursing action?
- Complaints of nausea and vomiting
- Blood pressure of 158/96 mmHg
- New onset of tonic-clonic seizure activity (Correct answer)
- Mild hand tremors and irritability
Correct answer: New onset of tonic-clonic seizure activity
Alcohol withdrawal seizures are a life-threatening emergency and require immediate intervention, including seizure precautions and notification of the provider for emergency benzodiazepine administration (lorazepam or diazepam). Mild tremors and elevated BP are common during withdrawal but are less urgent than an active seizure.
Question 5: A nurse is caring for an older adult client in a long-term care facility. The client has unexplained bruising in different stages of healing, fearfulness when a specific staff member enters the room, and recent withdrawal from activities. The nurse should first:
- Confront the suspected staff member directly
- Document the findings and report suspected abuse to the appropriate authority (Correct answer)
- Ask the client's family if they have noticed any changes at home
- Reassess the client in one week before making any reports
Correct answer: Document the findings and report suspected abuse to the appropriate authority
These are classic warning signs of elder abuse. Nurses are mandated reporters and are legally required to report suspected abuse to adult protective services or the state's designated authority. Documentation is essential. Confronting the suspected abuser could jeopardize the investigation and place the client at greater risk.
Question 6: A nurse is preparing to discharge a client who experienced a panic attack. Which statement by the client indicates a need for further teaching?
- 'I should practice diaphragmatic breathing when I feel anxious.'
- 'If I avoid all stressful situations, I won't have panic attacks.' (Correct answer)
- 'Regular exercise may help reduce the frequency of panic attacks.'
- 'I should contact my provider if panic attacks are occurring more frequently.'
Correct answer: 'If I avoid all stressful situations, I won't have panic attacks.'
Avoidance of all stressful situations is not a realistic or therapeutic coping strategy and may worsen anxiety over time. Effective management includes learning coping techniques (diaphragmatic breathing, progressive muscle relaxation), regular exercise, and following up with the provider. This statement indicates a need for further teaching.
NCLEX-PN Test #7 1
A nurse is caring for a client newly diagnosed with breast cancer who states, 'I know they made a mistake with the pathology report.
I don't have cancer.' Which nursing response is most therapeutic?