NCLEX RN Practice Test

Encouraging consistent hand hygiene is essential for a school-age child because it significantly reduces the risk of infectious diseases, such as colds and gastrointestinal illnesses, which are common in school settings. While advising on proper nutrition and hydration is also important to the child's growth and learning, and discussing bullying prevention is relevant to emotional health, hand hygiene directly supports physical health and aligns closely with the parent's concern for the child's safety and health in this context. Other options, such as teaching traffic safety, relate more broadly to safety but are less closely tied to the immediate concern about the school environment.

The correct answer is true. Withdrawal symptoms such as agitation, tremors, tachycardia, and confusion are hallmark signs of withdrawal from central nervous system depressants like alcohol and benzodiazepines. These symptoms occur because the central nervous system compensates for the lack of suppressive input from these substances by becoming hyperactive. Recognizing these signs allows for timely administration of interventions, such as benzodiazepines or supportive care. Incorrect answers stem from a failure to connect the clinical signs with substance withdrawal or may confuse them with symptoms of intoxication, which often include sedation rather than hyperactivity.

When prioritizing client care, the nurse should focus on addressing the patient with the greatest risk to life or critical bodily functions. This is often referred to as using the ABCs (Airway, Breathing, Circulation) of prioritization. In this case, a client with difficulty breathing presents an immediate threat to life, requiring prompt intervention. While conditions like post-surgery pain or monitoring IV fluids are important, they do not pose the same level of urgency as respiratory distress. Delegating tasks like ambulation assistance is also appropriate, but it is not urgent.

The correct answer is identifying who the client feels supported by because understanding the client's perception of their support system is crucial in determining who is actively involved in providing encouragement and assistance. Simply observing visitors or asking about family relations does not provide adequate insight into the perceived emotional and practical support available. Discussing future commitments provides information but does not assess the current state of the support system.

The correct answer is to adopt an early intervention to de-escalate the client's agitation in a safe manner. Speaking calmly and acknowledging the client's distress lowers the agitation level and demonstrates empathy, reducing the likelihood of violence. Close observation or additional security measures may be necessary but should follow attempts to de-escalate the situation. Restraining or isolating the client should be a last resort and used only when there is an imminent threat of harm. Focusing solely on observing without action risks escalation, and prematurely involving security can intensify the situation unnecessarily.

The correct approach is to collaborate with the client to align the medication schedule with their fasting hours while maintaining therapeutic effectiveness. This ensures respect for the client’s cultural and religious practices while prioritizing their health outcomes. Other options overlook the importance of respecting the client’s beliefs or fail to address the potential risks of altering the medication schedule arbitrarily. Effective planning requires understanding the client’s cultural context and working together to find a suitable solution.

The correct answer emphasizes de-escalation through calm communication and an understanding tone, which can diffuse the situation without escalating the client’s agitation. Giving strict instructions to sit down or stop disruptive behavior in a firm tone may escalate conflict, as it can be perceived as confrontational. Threatening removal is not therapeutic and may further upset the client rather than de-escalate the situation. Lastly, implementing physical measures is reserved for high-risk situations where the client poses an immediate threat and other strategies have been unsuccessful. De-escalating verbally is more appropriate as an initial approach.

The correct answer is to encourage the client to express their feelings about the guilt they’re experiencing. Actively listening and providing a safe space for the client to verbalize their emotions is a key part of therapeutic communication and grief support. Validating feelings helps the client begin to process their grief in a healthy manner. While providing information about grief stages or suggesting distractions may be helpful in later interventions, these responses are not the most effective initial actions when addressing the emotional intensity of guilt. Minimizing their guilt without exploration of their emotions disregards the client’s need for validation and recognition of their feelings.

The correct answer reflects the American Academy of Pediatrics' (AAP) safe sleep guidelines, which emphasize placing infants on their backs for sleep on a firm mattress within a crib without loose bedding. This position significantly reduces the risk of SIDS. Allowing side-lying sleep increases instability, potentially leading to dangerous rollovers. Car seats are not safe sleeping environments because of the risk of positional asphyxia. Loose blankets in the crib can raise the risk of suffocation or overheating, which are factors associated with SIDS.

Acknowledging a client’s emotional response fosters trust and demonstrates empathy, which is key to promoting positive coping strategies. Encouraging the client to express their concerns helps identify specific fears or misconceptions that can be addressed during the teaching session. This approach prioritizes understanding the client's perspective and lays the groundwork for effective care planning. Conversely, advising the client to focus on the benefits of their new routine might unintentionally minimize their current emotional struggle. Reassuring statements, such as 'It will get easier,' lack specificity and do not explore the deeper reasons behind the client’s distress. Offering solutions before fully understanding the client's perspective may hinder the therapeutic communication process and might not align with the client's immediate emotional needs.

The correct answer is to honor the client’s advance directive and discuss it with the family member. Advance directives are legal documents that reflect the client’s wishes. Respecting these preferences is paramount in providing ethically sound care. The nurse should use therapeutic communication to educate the family member about the client’s documented choices, ensuring they understand the significance of those decisions. Other options fail to prioritize the client’s autonomy: implementing life-prolonging interventions without consent violates legal and ethical principles, and referring the issue to the healthcare provider without addressing the family’s concerns fails to demonstrate patient advocacy or nurse-patient-family collaboration.

This statement is false because nurses, as mandated reporters, are required to report suspected abuse without needing to verify or confirm it. Their role is to identify warning signs and notify the proper authorities who will investigate further. Waiting for verification can delay intervention and potentially allow harm to continue. Any concerning signs such as behavioral changes or physical injuries should prompt a report to protect the client.

The correct response involves educating the family about the purpose of pain management in hospice care, specifically that the primary goal is to improve the patient's comfort and quality of life, not to hasten death. It is important to reassure the family that pain medications, such as opioids, are carefully prescribed and administered to address suffering while maintaining the highest possible level of well-being. Incorrect answers either fail to address the family's concerns, provide accurate information, or suggest actions that could compromise the patient's comfort. For example, suggesting discontinuing the medication ignores the patient's suffering, while focusing on other aspects of care dismisses the legitimate concerns raised by the family.

The correct answer is educating the client about the risks of substance misuse and offering resources for support. Substance misuse can have severe physical, mental, and social consequences, including dependency, impaired decision-making, and chronic health conditions. Nurses play an essential role in empowering clients with accurate information and access to resources to mitigate these risks. Although addressing peers' influence and consulting therapy are important, substance misuse education is the first step in reducing high-risk behaviors. Other options, like discouraging gathering with friends, do not directly target the issue.

The correct answer is appropriate because monitoring vital signs is commonly within the scope of practice for assistive personnel (AP), as long as the AP has been trained and the RN provides clear instructions and supervision. Tasks requiring assessment, interpretation, or critical decision-making—such as evaluating incision sites or administering medication—are outside the AP's scope of practice and must be performed by a licensed nurse.