after a lengthy explanation of a medical procedure the patient asks many questions the physician answers all of the questions to the best of her abili

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. After a lengthy explanation of a medical procedure, the patient asks many questions. The physician answers all of the questions to the best of their ability. The patient then gives consent for treatment. The costly equipment and supplies are put into place, and the patient is prepared. Two minutes before the procedure is to start, the patient begins panicking and changes their mind. Which of the following situations would be the best way to avoid litigation?

A. Document that the patient originally gave consent and proceed if the benefits of the procedure outweigh the patient's wishes.
B. Have the patient sign a form stating that they are refusing consent. If they refuse to sign, do not proceed with the procedure.
C. Repeat the explanation of the procedure until the patient understands that having the procedure done is the best form of treatment. Do not proceed with the procedure.
D. Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.

Correct answer: D

Rationale: In this scenario, the best course of action to avoid litigation is to respect the patient's right to refuse treatment, especially when changing their mind before the procedure starts. By not proceeding with the treatment, documenting the patient's refusal, and having the patient sign a refusal to consent form, you are following proper ethical and legal procedures. If the patient refuses to sign the form, having a witness available to sign further strengthens the documentation of the patient's decision. This approach ensures that the patient's autonomy and right to make informed decisions about their healthcare are respected. Choices A, B, and C do not prioritize the patient's right to refuse treatment and could potentially lead to legal issues if treatment is carried out against the patient's wishes.

2. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.

Correct answer: A

Rationale: The correct answer is when the adolescent gives away a DVD player and a cherished autographed picture of a performer. This behavior is concerning because a depressed suicidal client often gives away things of value as a way of saying goodbye and wanting to be remembered. Choices B, C, and D all involve anger and acting-out behaviors, which are common in adolescents but do not specifically indicate suicidal ideation. Running out of group therapy, swearing, and going to her room, becoming angry and slamming the phone receiver, or getting upset when her roommate borrows her clothes are not clear indications of suicidal thoughts.

3. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?

A. Do you mean your boyfriend?
B. Do you mean your boyfriend?
C. No one will ever hurt you again.
D. Tell me more about what happens when he gets angry.

Correct answer: D

Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.

4. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

A. Go get a blood pressure check within the next 15 minutes
B. Check blood pressure again in two (2) months
C. See the healthcare provider immediately
D. Visit the healthcare provider within one (1) week for a BP check

Correct answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

5. A systemic sign of infection is ______________.

A. swelling
B. redness
C. heat
D. a lack of appetite

Correct answer: D

Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.