NCLEX-PN Test #7 1

Question 1

A nurse is caring for a client newly diagnosed with breast cancer who states, 'I know they made a mistake with the pathology report. I don't have cancer.' Which nursing response is most therapeutic?

Accepted Answer

'I understand this news is very difficult. What are your thoughts and feelings right now?'

Answer

The client is in the denial stage of grief. The most therapeutic response acknowledges the client's feelings and invites open communication. Pushing the client toward acceptance or jumping into treatment planning dismisses emotional needs. Offering a second opinion is not therapeutic communication and may reinforce denial.

Question 2

A nurse is caring for a client with major depressive disorder who states, 'I've been giving away my things and I've said goodbye to my family. I feel at peace now.' How should the nurse interpret this?

Accepted Answer

The client is showing warning signs of imminent suicide

Answer

Giving away possessions, saying goodbyes, and sudden calmness (a 'peaceful' feeling after a period of depression) are critical warning signs of an imminent suicide attempt. The nurse must conduct a direct suicide risk assessment, notify the provider, and implement safety precautions immediately.

Question 3

A nurse is providing care to a client with schizophrenia who says, 'The TV is sending me special messages.' Which response by the nurse is most therapeutic?

Accepted Answer

'I don't see evidence that the TV is sending you messages, but I can see you are distressed.'

Answer

The nurse should neither reinforce nor argue with delusions. The therapeutic response acknowledges the client's emotional experience (distress) without validating the delusion. Asking about message content can reinforce the delusion. Dismissing the belief without empathy breaks therapeutic rapport.

Question 4

A nurse is caring for a client with alcohol use disorder who is on day 2 of detoxification. The client suddenly becomes agitated, diaphoretic, and tremulous. Which finding would require the most urgent nursing action?

Accepted Answer

New onset of tonic-clonic seizure activity

Answer

Alcohol withdrawal seizures are a life-threatening emergency and require immediate intervention, including seizure precautions and notification of the provider for emergency benzodiazepine administration (lorazepam or diazepam). Mild tremors and elevated BP are common during withdrawal but are less urgent than an active seizure.

Question 5

A nurse is caring for an older adult client in a long-term care facility. The client has unexplained bruising in different stages of healing, fearfulness when a specific staff member enters the room, and recent withdrawal from activities. The nurse should first:

Accepted Answer

Document the findings and report suspected abuse to the appropriate authority

Answer

These are classic warning signs of elder abuse. Nurses are mandated reporters and are legally required to report suspected abuse to adult protective services or the state's designated authority. Documentation is essential. Confronting the suspected abuser could jeopardize the investigation and place the client at greater risk.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #7 1