NCLEX NCLEX-PN
2024 Nclex Questions
1. Which of the following factors can impact an individual’s ability to give informed consent?
- A. IQ
- B. educational level
- C. pain medications
- D. financial status
Correct answer: pain medications
Rationale: Pain medications might alter alertness, thought processes, and reactions, potentially impacting an individual's ability to give informed consent. It is recommended to approach a client for consent at least 4 hours after the last dose of pain medicine to minimize any influence. Choices A, B, and D are incorrect. While IQ and educational level may affect how information is presented during the discussion process, they do not directly impact informed-consent decision-making. Financial status is also not a direct factor in an individual's ability to provide informed consent, unlike pain medications which can directly affect cognitive functions and decision-making abilities.
2. What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
- A. Discussing the repetitive actions.
- B. Insisting the client not perform the repetitive act.
- C. Informing the client that the act is not necessary.
- D. Encouraging daily exercise.
Correct answer: Encouraging daily exercise.
Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
3. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with quiet activities
- C. identifying the child’s home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct answer: identifying the child’s home bedtime rituals and following them
Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.
4. A two-year-old has been in the hospital for 3 weeks and has seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
- A. Guilt
- B. Trust
- C. Separation anxiety
- D. Shame
Correct answer: C
Rationale: The correct answer is 'Separation anxiety.' Separation anxiety is a common response in young children when they are separated from their primary caregivers for extended periods. In this case, the two-year-old being in the hospital for three weeks and not being able to see family members due to isolation precautions can trigger separation anxiety. 'Guilt' is a feeling of responsibility for wrongdoing, which is not the most likely change occurring in this scenario. 'Trust' involves reliance and confidence in others, not typically associated with prolonged separation from family. 'Shame' is a negative emotion related to feeling disgrace, which is not the most appropriate response in this hospitalization situation.
5. To decrease a client’s use of denial and increase the client’s expression of feelings, what should the nurse do?
- A. Tell the client to stop using the defense mechanism of denial
- B. Positively reinforce each expression of feelings
- C. Instruct the client to express feelings
- D. Challenge the client each time denial is used
Correct answer: Positively reinforce each expression of feelings
Rationale: The most appropriate approach to decrease a client’s use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.
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