NCLEX Question of The Day

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The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

  • A. Engage the client to walk with you to make another pot of coffee
  • B. Ask the client to reflect on their behavior to determine if it is appropriate
  • C. Ask the group to tell the client how they feel when she interrupts
  • D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy
Correct Answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

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A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?

  • A. Memory loss and lack of appetite
  • B. Confusion and fatigue
  • C. Heightened reflexes
  • D. Tinnitus and spasticity
Correct Answer: B

Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.

While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?

  • A. Recommend a dermatological consult to the physician.
  • B. Note the location of the mole and contact the physician via telephone.
  • C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
  • D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Correct Answer: C

Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.

A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

  • A. Call the surgeon immediately.
  • B. Administer Extra Strength Tylenol per orders.
  • C. Assess the surgical site.
  • D. Offer extra blankets and increase fluids.
Correct Answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.

A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

  • A. Sore throat
  • B. Vertigo
  • C. Fever
  • D. Shortness of breath
Correct Answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

  • A. Muscle tetany
  • B. Syncope
  • C. Numbness
  • D. Anxiety
Correct Answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

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