NCLEX-PN Test #15 2 Flashcards

A client newly diagnosed with breast cancer says, "Why is this happening to me? I've lived a healthy life." The nurse's best response is:

Answer: "It sounds like you're feeling angry and questioning why this happened. That's a very understandable reaction."

This response validates the client's emotional experience without dismissing, deflecting, or providing false reassurance. Acknowledging feelings (anger, confusion) using reflection is a core therapeutic communication technique that builds trust and encourages the client to express further concerns. Platitudes ("everything happens for a reason") block therapeutic communication.

The nurse is using motivational interviewing with a client who wants to quit smoking but feels ambivalent. Which nursing statement best reflects a motivational interviewing technique?

Answer: "Tell me about the times you've successfully made other changes in your life."

Motivational interviewing (MI) is a collaborative, empathetic approach that explores the client's own motivations and strengths. Asking about past successful changes evokes self-efficacy (affirming technique). MI avoids confrontation (options A, D) and one-way information delivery (option C). It focuses on the client's own values and goals.

A client experiencing grief after the death of a spouse says, "I keep thinking I hear him in the next room." How should the nurse respond?

Answer: "Experiencing these sensations is a common and normal part of grief — it doesn't mean anything is wrong with you."

Grief hallucinations (sensing or hearing the deceased) are a common, normal aspect of acute grief, not a sign of psychosis. Normalizing this experience reduces the client's distress and shame. Pathologizing normal grief (options A, D) or dismissing it (option C) is non-therapeutic and can harm the grieving process.

A client refuses a blood transfusion on religious grounds despite a life-threatening hemoglobin level of 5.2 g/dL. What is the appropriate nursing response?

Answer: Document the refusal, notify the provider and ethics team, and continue to support the client's decision-making autonomy

Competent adult clients have the absolute right to refuse medical treatment, including blood products, even if the refusal may result in death. The nurse must: respect the client's autonomy and informed refusal, document the refusal thoroughly, notify the provider, explore alternatives (cell saver, erythropoietin, iron infusion), and involve ethics consultation.

The PN is caring for a client from a culture different from their own. Which approach best demonstrates cultural competence?

Answer: Ask the client directly about their cultural beliefs, practices, and preferences related to their care

Cultural competence requires individually assessing each client's beliefs and practices — not assuming based on ethnicity or applying cultural generalizations. Asking the client directly about their cultural health beliefs, dietary restrictions, spiritual needs, and care preferences is the most respectful and accurate approach.

A client with advanced dementia begins crying during a bath. Which nursing response is most therapeutic?

Answer: Pause the bath, speak calmly and reassuringly, use gentle touch, and consider whether discomfort or fear is the cause

For clients with dementia, distress during care often indicates pain, fear, cold, or overstimulation — not simply resistance. Pausing, assessing for discomfort, using gentle reassuring communication, and adjusting the approach (warm water temperature, covering areas not being washed, using familiar soap) reduces distress. Person-centered dementia care minimizes the use of sedation.