NCLEX-PN Test #4 3

Question 1

A client with generalized anxiety disorder reports, "I can't stop worrying about everything — my job, my family, everything." Which therapeutic response is most appropriate?

Accepted Answer

"It sounds like you're feeling overwhelmed by worry. Can you tell me more?"

Answer

The therapeutic response validates the client's feelings and uses an open-ended question to encourage further expression. This demonstrates empathy and active listening. Giving advice (options A, B, D) dismisses the client's experience and can inhibit therapeutic communication.

Question 2

A client with bipolar disorder is in a manic episode. Which nursing intervention is the priority?

Accepted Answer

Provide a low-stimulation environment and set limits on behavior

Answer

During mania, reducing environmental stimulation is the priority to prevent escalation. Clients in manic states are highly distractible and at risk for exhaustion, impulsive behavior, and self-harm. Group activities can over-stimulate. SSRIs are contraindicated in mania as they can worsen the episode.

Question 3

The PN is caring for a client with anorexia nervosa who is being re-fed. Which complication must the nurse monitor for most closely?

Accepted Answer

Refeeding syndrome (hypophosphatemia)

Answer

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation after starvation. Rapid carbohydrate intake triggers insulin release and shifts phosphate, potassium, and magnesium into cells, causing severe hypophosphatemia. The nurse must monitor electrolytes closely during refeeding.

Question 4

A client is prescribed lithium carbonate for bipolar disorder. Which symptom indicates lithium toxicity?

Accepted Answer

Coarse hand tremor, ataxia, and confusion

Answer

Coarse tremor (vs. fine tremor which is a mild side effect), ataxia (loss of coordination), and confusion are signs of lithium toxicity (serum level >1.5 mEq/L). Therapeutic range is 0.6–1.2 mEq/L. Toxicity can progress to seizures and death. Polyuria/polydipsia are common early non-toxic side effects.

Question 5

A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the most therapeutic nursing response?

Accepted Answer

Speak in a calm, clear voice, orient the client to the present, and ensure safety

Answer

During a flashback, grounding techniques help bring the client back to the present moment. The nurse should speak calmly and clearly, provide orienting cues ("You are safe, you are in the hospital"), and ensure the environment is safe. Pressing the client to discuss trauma details during acute distress is contraindicated.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #4 3