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Nclex 2024 Questions
1. Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct answer: denial and fantasy
Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.
2. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, “No woman will ever want to marry me now.” Which of the following responses by the nurse is most therapeutic?
- A. “Don’t worry. Maybe you’ll meet a paraplegic woman.”
- B. “There is someone for everyone in this world.”
- C. “You are still an attractive man, even though you can’t walk.”
- D. “Tell me more about your feelings on this issue.”
Correct answer: “Tell me more about your feelings on this issue.”
Rationale: The correct response is 'Tell me more about your feelings on this issue.' This answer is the most therapeutic as it encourages the client to express his emotions and concerns, fostering a supportive and open dialogue between the client and the nurse. Option A may come across as dismissive and does not directly address the client's emotional state. Option B, while positive, oversimplifies the client's complex feelings. Option C focuses only on physical appearance, missing the opportunity to delve deeper into the client's emotional well-being. Therefore, the most therapeutic response is to encourage further discussion about the client's feelings.
3. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?
- A. The young adult is sensitive to criticism.
- B. The young adult verbalizes unrealistic fears.
- C. The young adult verbalizes disappointment with life.
- D. The young adult verbalizes satisfaction with friendships.
Correct answer: The young adult verbalizes satisfaction with friendships.
Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.
4. Which of the following observations is most important when assessing a client’s breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct answer: presence of breathing and adequacy of breathing
Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial not only to confirm that the client is breathing but also to ensure that the breathing is adequate for proper oxygenation. Choices A, B, and D are incorrect because while pulse rate, breathing pattern, and patient position are relevant aspects to consider, the most critical observations in assessing a client's breathing are the presence and adequacy of breathing.
5. When planning for the physical assessment of the woman, the nurse ensures that which occurs?
- A. The woman is examined by a female health care provider.
- B. The woman's husband remains in the examining room at all times.
- C. The woman is examined without any other people in the examining room.
- D. Written permission is obtained from the woman to obtain subjective health data.
Correct answer: The woman is examined by a female health care provider.
Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman’s genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.
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