HURST REVIEW NCLEX RN READINESS EXAM 2: LATEST A+
QUESTIONS AND ANSWERS EDITION.
During evening rounds, the nurse discovers that a violent client with a history of
threats against a former girlfriend cannot be located. The client's window is open
and personal belongings missing. Based on recent threats of violence against the
girlfriend, what is the nurse's initial action?
3. Initiate the missing client protocol.
The nurse is teaching a class to primiparas on breastfeeding. How many extra
kilocalories per day would the nurse instruct the class participants to consume
post-delivery to compensate for the increased energy requirements of lactation?
3. 500
A client who has been on a psychiatric unit because of several attempted
suicides states, "I am happy to be going home today." What is the nurse's best
analysis of this statement?
3. May have decided on another suicide plan.
A teenage client is placed on life-support as a result of a motor vehicle accident
(MVA). Following an electroencephalogram (EEG), the client has been declared
brain dead. Which action by the nurse would take priority?
3. Contact the regional organ procurement team.
A nurse is attempting to develop trust with a psychiatric client exhibiting
concrete thinking. Which nursing intervention would promote trust in this
individual?
1. Attend an activity with the client who is reluctant to go alone.
3. Consider client preferences when possible in decisions concerning care.
4. Provide a blanket when the client is cold.
5. Provide food when the client is hungry.
The occupational health nurse is leading a group discussion about addiction.
What should the nurse include as the primary barrier to the client with alcohol
addiction seeking treatment?
2. Denial
, The nurse is planning daily activities for a client who has a diagnosis of
schizophrenia. The client tends to spend most of the time in bed and is very
uncomfortable when other clients are in the day area of the unit. What activity
would be most therapeutic for this client?
3. Spending time in brief one on one interactions with the nurse.
A parent tells the clinic nurse, "My child has just been diagnosed with attention-
deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How
should the nurse best respond to the parent?
4. The standard of care for children with ADHD includes central nervous system
stimulants along with behavior and family therapy.
A home care nurse is preparing to perform venipuncture to draw blood. As the
nurse gathers supplies, the client begins to experience palpitations, trembling,
nausea, shortness of breath and a feeling of losing control. What should be the
nurse's first action?
3. Decrease stimuli in the room.
A client is seen in the clinic for recurrent unexplained, vague stomach pain over
the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have
revealed no physical reason for the symptoms. The client tells the nurse, "The
doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad
some times that I can't function!" What is the nurse's most appropriate response?
1. "The pain you feel is real."
The nurse is caring for a client suffering from major depression. The client
spends all day in bed. Which nursing action is appropriate?
1. Frequently initiate contact with client.
Which interventions should the nurse include when planning care for a client
diagnosed with paranoid personality?
1. Develop a trusting relationship.
2. Be honest when communicating with the client.
5. Give clear explanations of procedures before hand.
QUESTIONS AND ANSWERS EDITION.
During evening rounds, the nurse discovers that a violent client with a history of
threats against a former girlfriend cannot be located. The client's window is open
and personal belongings missing. Based on recent threats of violence against the
girlfriend, what is the nurse's initial action?
3. Initiate the missing client protocol.
The nurse is teaching a class to primiparas on breastfeeding. How many extra
kilocalories per day would the nurse instruct the class participants to consume
post-delivery to compensate for the increased energy requirements of lactation?
3. 500
A client who has been on a psychiatric unit because of several attempted
suicides states, "I am happy to be going home today." What is the nurse's best
analysis of this statement?
3. May have decided on another suicide plan.
A teenage client is placed on life-support as a result of a motor vehicle accident
(MVA). Following an electroencephalogram (EEG), the client has been declared
brain dead. Which action by the nurse would take priority?
3. Contact the regional organ procurement team.
A nurse is attempting to develop trust with a psychiatric client exhibiting
concrete thinking. Which nursing intervention would promote trust in this
individual?
1. Attend an activity with the client who is reluctant to go alone.
3. Consider client preferences when possible in decisions concerning care.
4. Provide a blanket when the client is cold.
5. Provide food when the client is hungry.
The occupational health nurse is leading a group discussion about addiction.
What should the nurse include as the primary barrier to the client with alcohol
addiction seeking treatment?
2. Denial
, The nurse is planning daily activities for a client who has a diagnosis of
schizophrenia. The client tends to spend most of the time in bed and is very
uncomfortable when other clients are in the day area of the unit. What activity
would be most therapeutic for this client?
3. Spending time in brief one on one interactions with the nurse.
A parent tells the clinic nurse, "My child has just been diagnosed with attention-
deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How
should the nurse best respond to the parent?
4. The standard of care for children with ADHD includes central nervous system
stimulants along with behavior and family therapy.
A home care nurse is preparing to perform venipuncture to draw blood. As the
nurse gathers supplies, the client begins to experience palpitations, trembling,
nausea, shortness of breath and a feeling of losing control. What should be the
nurse's first action?
3. Decrease stimuli in the room.
A client is seen in the clinic for recurrent unexplained, vague stomach pain over
the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have
revealed no physical reason for the symptoms. The client tells the nurse, "The
doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad
some times that I can't function!" What is the nurse's most appropriate response?
1. "The pain you feel is real."
The nurse is caring for a client suffering from major depression. The client
spends all day in bed. Which nursing action is appropriate?
1. Frequently initiate contact with client.
Which interventions should the nurse include when planning care for a client
diagnosed with paranoid personality?
1. Develop a trusting relationship.
2. Be honest when communicating with the client.
5. Give clear explanations of procedures before hand.
