a 22 year old patient in a mental health lock down unit under suicide watch appears happy about being discharged which of the following is probably ha a 22 year old patient in a mental health lock down unit under suicide watch appears happy about being discharged which of the following is probably ha
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Nursing Elites

NCLEX NCLEX-PN

NCLEX PN Exam Cram

1. A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?

Correct answer: The patient’s suicide plan has probably progressed.

Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.

2. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

Correct answer: “Her gums look too big for her teeth.”

Rationale: The correct answer is '“Her gums look too big for her teeth.”' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '“She is very irritable lately,”' is not a typical side effect of Dilantin. Option B, '“She sleeps quite a bit of the time,”' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '“She has gained about 10 pounds in the last 6 months,”' is not typically associated with Dilantin therapy and is unrelated to the question.

3. The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?

Correct answer: A red, beefy tongue

Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.

4. A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?

Correct answer: 16 weeks

Rationale: Fetal movements (quickening) are first noticed by multigravida pregnant women at 16 to 20 weeks of gestation and gradually increase in frequency and strength. This is when the mother typically begins to feel the baby's movements. Choices B, C, and D are incorrect because fetal movements are not felt as early as 6, 8, or 12 weeks of gestation. At 6 weeks, the embryo's movements are not yet strong enough to be felt by the mother. By 8 weeks, the movements are still too subtle to be perceived. At 12 weeks, although fetal movements start, they are usually not strong enough to be felt by the mother.

5. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

Correct answer: A problem with balance

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

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