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NCLEX-PN Exam Questions - Part 76
1. Paula is a 32-year-old woman seeking evaluation and treatment of major depressive symptoms. A major nursing priority during the assessment process includes which of the following?
A) meaning of current stressors
B) possibility of self-harm
C) motivation to participate in treatment
D) presence of alcohol or other drug use
2. A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
A) allow the client to work through independent problem-solving.
B) complete an in-depth evaluation of stressors and responses to the situation.
C) focus on immediate stress reduction.
D) recommend ongoing therapy.
3. A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor?
A) Adaptation Model
B) Stimulus-Based Model
C) Transaction-Based Model
D) Selye - s Model of Stress
4. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
A) brain
B) bone
C) liver
D) mediastinum
5. In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis?
A) ability to breathe
B) pallor or cyanosis of the skin
C) number of accompanying family members
D) motor function
A) meaning of current stressors
B) possibility of self-harm
C) motivation to participate in treatment
D) presence of alcohol or other drug use
2. A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
A) allow the client to work through independent problem-solving.
B) complete an in-depth evaluation of stressors and responses to the situation.
C) focus on immediate stress reduction.
D) recommend ongoing therapy.
3. A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor?
A) Adaptation Model
B) Stimulus-Based Model
C) Transaction-Based Model
D) Selye - s Model of Stress
4. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
A) brain
B) bone
C) liver
D) mediastinum
5. In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis?
A) ability to breathe
B) pallor or cyanosis of the skin
C) number of accompanying family members
D) motor function
1. Right Answer: B
Explanation: Unless the client is first assessed for self-harm or suicide potential, the staff might not observe the necessary degree of vigilance needed in the clients environment. Physical needs are the second most critical concern with a depressive client. Though the client may be encouraged to attend group therapy as part of the treatment plan, the clients safety takes precedence. Response to medication takes time and is not an initial concern. Physiological Adaptation
2. Right Answer: C
Explanation: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning. Psychosocial Integrity
3. Right Answer: C
Explanation: The Transaction-Based Model is, according to R.S. Lazarus, a state that Stimulus theory and Response theory do not consider individual differences. He takes into account cognitive processes that intervene between the encounter and the reaction and the factors that affect the nature of this process. He includes mental and psychological components or responses as part of his concept of stress (Person Environment Transactions). Psychosocial Integrity
4. Right Answer: C
Explanation: Colon tumors tend to spread through the lymphatics and portal vein to the liver. Although metastasis to the other sites listed is possible, the liver is most likely the first to be affected. Physiological Adaptation
5. Right Answer: C
Explanation: The least important factor (of those listed) during an emergency situation is the number of accompanying family members. Safety and Infection Control
Explanation: Unless the client is first assessed for self-harm or suicide potential, the staff might not observe the necessary degree of vigilance needed in the clients environment. Physical needs are the second most critical concern with a depressive client. Though the client may be encouraged to attend group therapy as part of the treatment plan, the clients safety takes precedence. Response to medication takes time and is not an initial concern. Physiological Adaptation
2. Right Answer: C
Explanation: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning. Psychosocial Integrity
3. Right Answer: C
Explanation: The Transaction-Based Model is, according to R.S. Lazarus, a state that Stimulus theory and Response theory do not consider individual differences. He takes into account cognitive processes that intervene between the encounter and the reaction and the factors that affect the nature of this process. He includes mental and psychological components or responses as part of his concept of stress (Person Environment Transactions). Psychosocial Integrity
4. Right Answer: C
Explanation: Colon tumors tend to spread through the lymphatics and portal vein to the liver. Although metastasis to the other sites listed is possible, the liver is most likely the first to be affected. Physiological Adaptation
5. Right Answer: C
Explanation: The least important factor (of those listed) during an emergency situation is the number of accompanying family members. Safety and Infection Control
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