NCLEX-PN
2024 Nclex Questions
1. When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
- A. Constantly observing the client to prevent self-harm.
- B. Enlisting the client in defining and describing harmful behaviors.
- C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
- D. Removing all items from the environment that the client could use to harm themselves.
Correct answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.
2. Activities of effective supervisors can be task-related or people-related activities. An example of a task-related supervisory activity is:
- A. coaching.
- B. evaluating.
- C. delegating.
- D. facilitating.
Correct answer: C
Rationale: Delegating is the act of assigning work to those capable and competent to do the work, making it a task-related supervisory activity. Coaching, evaluating, and facilitating are people-related supervisory activities. Coaching involves guiding and developing individuals, evaluating entails assessing performance, and facilitating focuses on enabling tasks and processes. These activities are more centered on interacting with and supporting people rather than directly assigning tasks. Therefore, in the context of task-related activities, delegating stands out as the correct choice.
3. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
- A. A history of radiation treatment in the neck region
- B. A history of recent orthopedic surgery
- C. A history of minimal physical activity
- D. A history of the client's food intake
Correct answer: A
Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.
4. Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.
5. In a brief treatment program for a client who was raped, what is a realistic short-term goal?
- A. Identify all psychosocial problems.
- B. Eliminate the client's enticing behaviors.
- C. Resolve feelings of trauma and fear.
- D. Verbalize feelings about the event.
Correct answer: D
Rationale: In this scenario, a realistic short-term goal for the client who was raped and starting a brief treatment program is to verbalize feelings about the event. This goal promotes the expression of emotions, which is crucial in the healing process. Identifying all psychosocial problems is too broad and not typically achievable in a brief treatment program. Eliminating the client's enticing behaviors is not a suitable short-term goal as the focus should be on emotional recovery. While resolving feelings of trauma and fear is important, verbalizing feelings about the event is a more specific and achievable goal in the short term.
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