a client with schizophrenia and his parents are meeting with the nurse one of the young man9s parents says to the nurse we were stunned when we learne a client with schizophrenia and his parents are meeting with the nurse one of the young man9s parents says to the nurse we were stunned when we learne
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Nursing Elites

NCLEX NCLEX-PN

PN Nclex Questions 2024

1. A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, 'We were stunned when we learned that our son had schizophrenia. He was no different from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication.' Which response by the nurse is appropriate?

Correct answer: Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'

Rationale: The appropriate response is to ask the client how they can be helped in taking their medication or sharing problems to adjust the medication. This approach promotes direct communication with the client, allowing for better assessment of the situation and understanding the client's motivations and behaviors. It also encourages openness and mutual communication between the client and their family. Choice A provides important information about noncompliance as a common reason for relapse but lacks a therapeutic approach by not facilitating emotional expression. Choice B uses a threatening message and is nontherapeutic. Choice D prematurely analyzes the client's motivations without sufficient assessment and lacks a therapeutic communication style.

2. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

Correct answer: Murphy sign

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

3. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:

Correct answer: To lower the ammonia level

Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.

4. A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?

Correct answer: trachea deviating to the right

Rationale: The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context. Choice A, a temperature of 102°F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift. Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax. Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.

5. A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?

Correct answer: Intermittent claudication

Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. The client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces them to stop, with the pain subsiding after rest. The pain is reproducible, and as the disease progresses, the client can walk shorter distances before the pain recurs. Ultimately, pain may even occur at rest. Venous insufficiency (Choice A) involves impaired blood flow in the veins, leading to swelling and skin changes but not typically pain associated with exercise. Sore muscles from overexertion (Choice C) and muscle cramps related to musculoskeletal problems (Choice D) do not present with the characteristic pattern of pain associated with peripheral artery disease.

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