NCLEX PN Actual Exam Test Bank Newest With Complete 500 Questions And

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NCLEX PN Actual Exam Test Bank Newest 2025/2026 With Complete 500+ Questions And Correct Answers |Already Graded A+||Brand New Version!|

Which of the following symptoms are consistent with schizophrenia?

SATA

• Disorganized speech
• Flat effect
• Laughing for no apparent reason
• Loss of interest in pleasurable activities
• Self care deficit - ANSWER-A, B, C, D, E

Which complication of schizophrenia should the nurse be MOST concerned about?

• Anxiety
• Insufficient nutritional intake
• Self-harm
• Substance use disorder - ANSWER-C

Self harm and suicide is the most concerning complication as the rates are higher in patients with schizophrenia.

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The nurse assists the RN with development of the POC. For each intervention, specify if the intervention is appropriate or not appropriate for the care of the client with schizophrenia.Allow the client to listen to music Use gentle touch to calm the client Open medication packages in front of the client Tell the client that you DO NOT believe that the voices are real Ask the client if he is hearing voices instructing him to self-harm -

ANSWER-Appropriate: Allow the client to listen to music, open

medication packages in front of the client, and ask the client if he is hearing voices instructing him to self-harm

NOT Appropriate: Use gentle touch to calm the client and tell the client

that you DO NOT believe that the voices are real

Do not touch the client without warning. Do not discredit the client's beliefs as it can worsen paranoia.

Which action should the nurse perform FIRST for the schizophrenic patient?

• Administer lorazepam, haloperidol, and diphenhydramine
• Direct other clients away from the area
• Offer the client distraction activities
• Place the client in 4 point restraints
• Request additional staff presence - ANSWER-B 2 / 4

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The nurse must recognize signs of escalating agitation (pacing, yelling, clenching fist) and intervene immediately to maintain a safe environment.

The nurse is caring for the schizophrenic client 6 days after admission.For each finding click to specify whether the finding indicates that the client's status had improved or not improved.Client is seen talking alone in the hallway Client is seen playing board games with peers Client asks the technician for hygiene supplies Client states, "The voices are a part of my illness." Client refuses to take medication from a new nurse - ANSWER-

IMPROVED: Client is seen playing board games with peers, client asks

the technician for hygiene supplies, client states, "The voices are a part of my illness."

NOT IMPROVED: Client is seen talking alone in the hallway and client

refuses to take medication from a new nurse

The nurse is caring for a client diagnosed with a DVT 1 day ago. Which action by the client would require immediate intervention by the nurse?

• Ambulates through the hallway several times per day
• Applies a warm compress to the site of inflammation
• Elevates the limb above the level of the heart when in bed
• Massages the affected leg to reduce pain and swelling - ANSWER-D 3 / 4

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Massaging the site might lead to development of a life threatening pulmonary embolism.

DVT interventions include anticoagulants, warm compress, elevation of limb, early ambulation.

A post operative client with obesity and DM has an abdominal wound and is at risk for poor wound healing. Which of the following intervention does the nurse anticipate to prevent wound dehiscence?

SATA

• Administer docusate sodium PO every day
• Assist in applying a abdominal binder
• Implement cardiac restriction to promote weight loss
• Monitor blood glucose to maintain tight control
• Reinforce teaching to hug a pillow while coughing - ANSWER-A, B,

D, E

A Spanish speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both English and Spanish, that a exploratory laparotomy is needed to determine the cause of obstruction and the possible causes include intestinal adhesion and ovarian or colon cancer. The surgeon asks the client to translate this information for the client and assist with translating the consent for,.Which action y the nurse would be most appropriate?

• Act as a witness for informed consent
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