NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 179 )

Updated On: 12-Jan-2026

A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

  1. Placing her in seclusion until the behavior is under control
  2. Walking up to the client and touching her on the arm to get her attention
  3. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
  4. Confronting the client, letting her know the consequences for getting angry and disrupting the unit

Answer(s): C

Explanation:

(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.



The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

  1. Ordering a full liquid diet for her
  2. Ordering five small meals for her
  3. Ordering a mechanical soft diet for her
  4. Ordering a puréed diet for her

Answer(s): C

Explanation:

(A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first.



A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:

  1. Afterbirth pains
  2. Constipation
  3. Cystitis
  4. A hematoma of the vagina or vulva

Answer(s): D

Explanation:

(A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with "severe pain." (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure.
Further assessments are indicated for this client.



Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

  1. Eating three large meals a day
  2. Drinking small amounts of liquids with meals
  3. Taking a long walk after meals
  4. Eating a low-carbohydrate diet

Answer(s): D

Explanation:

(A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping.



A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?

  1. Oral
  2. IM
  3. IV
  4. Aerosol

Answer(s): D

Explanation:

(A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.



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