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National Council Licensure Examination - NCLEX-RN Questions 338–340 (page: 137)

Updated On: 9-Feb-2026

A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

  1. Seclude him in his room.
  2. Set limits on his behavior.
  3. Have his medication increased.
  4. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

Answer(s): B

Explanation:

(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.



A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

  1. Encourages the client to discuss the voices
  2. Attempts to direct the client's attention to the here and now
  3. Exhibits sincere interest in the delusional voices
  4. Gives the medication as necessary for the acting-out behavior

Answer(s): B

Explanation:

(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.



A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

  1. Encourages the client to discuss the voices
  2. Attempts to direct the client's attention to the here and now
  3. Exhibits sincere interest in the delusional voices
  4. Gives the medication as necessary for the acting-out behavior

Answer(s): B

Explanation:

(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.



A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?

  1. Klebsiellapneumonia
  2. Pneumococcal pneumonia
  3. Legionella pneumophilapneumonia
  4. Escherichia colipneumonia

Answer(s): B

Explanation:

(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E.colipneumonia is caused by gram-negative bacteria.



A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?

  1. Klebsiellapneumonia
  2. Pneumococcal pneumonia
  3. Legionella pneumophilapneumonia
  4. Escherichia colipneumonia

Answer(s): B

Explanation:

(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E.colipneumonia is caused by gram-negative bacteria.



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