NCLEX-RN Nursing — All Questions

A nurse on a postpartum unit sees an unfamiliar woman in scrubs carrying a newborn down the hallway in her arms. What should the nurse do?

• a.Stop the woman at once and call security while checking her badge✓
• b.Report the observation to the charge nurse at the end of rounds
• c.Follow the woman to the nursery and confirm the infant's identity
• d.Return to the mother's room and confirm the infant was discharged

The National Center for Missing and Exploited Children lists as an essential guideline that infants are pushed in a bassinet rather than carried in anyone's arms, and that only staff wearing the distinctive infant-transport identification may move an infant, so carrying a newborn down a hallway is itself the warning sign. Because most hospital abductors impersonate staff and leave quickly, the nurse intervenes and summons security in the moment rather than tracking the infant afterward.

A nurse must move a 250-lb client who cannot bear any weight from the bed to a chair. Which approach best protects both the client and the staff?

• a.Use a draw sheet and lift the client with three staff members
• b.Use a gait belt and pivot the client with a second staff member
• c.Use a powered full-body lift with a second staff member assisting✓
• d.Use the overhead trapeze and coach the client to pull himself up

A client who cannot bear weight is transferred with a powered full-body sling lift, because OSHA identifies transfer and lifting devices as the key control for injury to both clients and staff during transfers. A gait belt and pivot transfer require the client to bear weight, and adding staff to a manual lift divides the load but still leaves each person handling more than manual technique makes safe.

At the bedside a nurse notices that a heparin syringe drawn up by another nurse holds ten times the ordered dose, and returns it to the pharmacy before any of it is given. What should the nurse do next?

• a.File an event report for the near miss in the facility's system✓
• b.Tell the other nurse privately and let her decide whether to report
• c.Document the correct dose given later in the client's medical record
• d.Wait to report unless the same error occurs again on the unit

A near miss is a patient safety event that did not reach the client, and AHRQ treats it as reportable precisely because near misses are far more common than adverse events and expose the system weaknesses that produce later harm. Charting the dose that was eventually given records nothing about what nearly happened, so documentation alone leaves the hazard invisible to the organization.

A nurse sees a colleague withdraw a full vial of hydromorphone, give a partial dose, waste none of the remainder, and put the syringe in her pocket. Which action should the nurse take?

• a.Ask the colleague to waste it with a witness at shift end
• b.Record the discrepancy in the controlled substance log only
• c.Report the observation to the charge nurse without delay✓
• d.Watch the colleague's practice over the next several shifts

Suspected diversion of a controlled substance is an immediate threat to clients, and NCSBN describes early recognition and reporting as the nurse's responsibility for keeping clients safe and getting the colleague help, so it is escalated to nursing leadership right away rather than investigated privately. Correcting the waste later or noting it only in the log leaves a possibly impaired colleague caring for clients in the meantime.

A nurse is teaching poison safety to the parents of a 2-year-old. Which statement by a parent indicates a need for further teaching?

• a.We keep pills in their original child-resistant bottles
• b.We call 1-800-222-1222 before we do anything else
• c.We keep syrup of ipecac on hand to make him vomit✓
• d.We store the drain cleaner in a locked cabinet up high

The American Academy of Pediatrics withdrew its recommendation for home ipecac in 2003 and advises that any ipecac already in the home be discarded, since inducing vomiting does not improve outcomes and carries its own risks. Calling Poison Help at 1-800-222-1222 first, locking up caustics out of reach, and leaving medicines in child-resistant packaging are all correct practices.

A nurse is discussing car seat use with the parent of a 14-month-old. Which statement by the parent indicates that the teaching was effective?

• a.She rides rear-facing until she outgrows the seat's height or weight limit✓
• b.She can turn forward-facing now that she is over one year old
• c.She can move to a booster seat as soon as she turns four years old
• d.She can ride in the front seat once she can buckle herself in

The AAP and NHTSA both frame rear-facing as a height-and-weight rule rather than a birthday: the child rides rear-facing until she reaches the highest weight or height her car safety seat allows, which for most convertible seats is well past age two. Turning a 14-month-old forward-facing because she has passed her first birthday applies an age-based rule that is no longer recommended, and the back seat remains the safest place for children younger than 13.

A nurse at a women's health clinic is counseling a 24-year-old client who plans to conceive within the next year. Which statement by the client indicates that the teaching about folic acid was effective?

• a.I should begin folic acid only if a prior baby had a birth defect.
• b.I should begin folic acid at the start of my second trimester.
• c.I should begin folic acid once a home pregnancy test is positive.
• d.I should take 400 micrograms of folic acid every day before I conceive.✓

CDC advises that all women capable of becoming pregnant take 400 mcg of folic acid daily, starting at least a month before conception, because the neural tube closes in the earliest weeks of pregnancy. Waiting for a positive pregnancy test is the most tempting error, but by then most of the window for preventing neural tube defects has already passed.

A client at 28 weeks' gestation received Tdap during a pregnancy two years ago and asks the nurse whether she needs the vaccine again. Which response by the nurse is correct?

• a.Tdap is given in the first trimester so antibodies have time to build.
• b.Tdap is given in every pregnancy, ideally between 27 and 36 weeks.✓
• c.Tdap is given after delivery, before you go home from the hospital.
• d.Tdap is given once every ten years, so you are not due for it now.

CDC recommends a Tdap dose during each pregnancy at 27 through 36 weeks' gestation, preferably early in that window, regardless of when the client last received Tdap or Td, because maternal antibodies cross the placenta and protect the infant before the infant's own pertussis series begins. The ten-year interval applies to tetanus boosters outside pregnancy and does not replace the dose given in each pregnancy.

A nurse is triaging telephone calls from clients in the third trimester. Which report requires the most immediate follow-up?

• a.Swelling of both ankles at the end of a long day on her feet
• b.Irregular tightening of the abdomen that stops when she walks
• c.A headache for two days that is worsening, with spots in her vision✓
• d.Heartburn after evening meals that eases when she sits upright

A persistent headache that is getting worse, together with visual changes, is an urgent maternal warning sign for preeclampsia and needs same-day evaluation. Dependent ankle edema, positional heartburn, and irregular tightening that resolves with activity are common third-trimester discomforts rather than emergencies.

A nurse palpates a laboring client's contractions. One contraction begins at 0800 and ends at 0800:45; the next begins at 0804 and ends at 0805. How should the nurse document the frequency of these contractions?

• a.Every 5 minutes
• b.Every 4 minutes✓
• c.Every 3 minutes
• d.Every 45 seconds

Frequency is timed from the beginning of one contraction to the beginning of the next, so 0800 to 0804 is a frequency of every 4 minutes. Timing from the end of the first contraction to the start of the next (0800:45 to 0804, about 3 minutes) measures the resting interval, and 45 seconds is the duration of the first contraction, not its frequency.

Four hours after a vaginal birth, a nurse palpates the client's fundus two fingerbreadths above the umbilicus and displaced to the right. The fundus is firm, lochia rubra is moderate, and the oxytocin infusion is running at the ordered rate. Which action should the nurse take first?

• a.Increase the oxytocin infusion rate per the standing order
• b.Assist the client to the bathroom to empty her bladder✓
• c.Massage the uterine fundus with a cupped hand for 15 seconds
• d.Notify the provider of the fundal height and position now

A fundus that is firm but sits high and off midline points to a distended bladder displacing the uterus, and having the client void is the intervention the nurse can carry out independently; an overdistended bladder inhibits involution and raises the risk of postpartum hemorrhage. Fundal massage and more oxytocin treat uterine atony, which is not the problem here because the fundus is already firm, and calling the provider before the client voids delays the action that fixes the finding.

A nurse is completing discharge teaching with a client on postpartum day 2. Which statement by the client indicates that the teaching about when to call the provider was effective?

• a.I will call if I feel cramping while my newborn is breastfeeding.
• b.I will call if I soak through a pad in an hour or less.✓
• c.I will call if my discharge turns pinkish-brown later this week.
• d.I will call if my breasts feel full and firm on the third day.

Soaking one or more pads in an hour is an urgent maternal warning sign for postpartum hemorrhage and warrants immediate contact with the provider. The change to pinkish-brown lochia serosa around days 4 to 10, afterpains during breastfeeding, and breast fullness on about the third day are all expected postpartum findings.

On the first day after an uncomplicated birth, a client repeatedly retells the story of her labor and asks the nurse to bathe the newborn for her. The nurse plans newborn care teaching. Which action is most appropriate?

• a.Document that the client is showing impaired bonding with her newborn
• b.Have the client perform the bath now so she practices before discharge
• c.Give the client written bath instructions and ask her to read them today
• d.Meet the client's own comfort needs now and demonstrate the bath tomorrow✓

During Rubin's taking-in phase in the first one to three days, the client is focused on her own recovery and on processing the birth, so she is not yet ready to learn; readiness returns in the taking-hold phase around days 4 to 10, when clients actively seek newborn care instruction. Dependent behavior this early is expected and by itself is not evidence of impaired bonding.

At 1 minute of life a term newborn has a heart rate of 128, a weak irregular cry with slow respirations, some flexion of the extremities, a grimace when the nares are suctioned, and a pink trunk with blue hands and feet. What Apgar score should the nurse assign?

• a.5
• b.7
• c.8
• d.6✓

Scoring 2 for a heart rate above 100, 1 for slow and weak respiratory effort, 1 for some flexion, 1 for a grimace, and 1 for acrocyanosis totals 6. Awarding 2 for color is the common error: a pink body with blue hands and feet scores 1, and only a completely pink newborn scores 2.

A nurse is evaluating a new parent's understanding of safe infant sleep. Which statement indicates that the teaching was effective?

• a.My baby will sleep in our bed so I can reach him during the night.
• b.My baby will sleep in his crib with a thin bumper pad around it.
• c.My baby will sleep on his side with a rolled blanket at his back.
• d.My baby will sleep on his back in his own crib in our bedroom.✓

Back sleeping on a firm, flat surface in the infant's own crib or bassinet kept in the parents' room is the recommended arrangement, and room sharing without bed sharing substantially lowers the risk of sleep-related infant death. Side positioning is not protective because infants roll to the stomach, and rolled blankets, bumper pads, and the adult bed all add suffocation and entrapment hazards.

A newborn is delivered to a client whose prenatal laboratory results show a positive hepatitis B surface antigen. Which intervention should the nurse anticipate for this newborn?

• a.Hepatitis B vaccine alone, with the immune globulin held until 2 months of age
• b.Hepatitis B testing of the newborn's cord blood before any product is given
• c.Hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth✓
• d.Hepatitis B immune globulin alone, with the vaccine series begun at 2 months

An infant born to a client who is hepatitis B surface antigen positive needs both active and passive protection, hepatitis B vaccine plus hepatitis B immune globulin, within 12 hours of birth. Giving only one of the two agents, or waiting on cord blood testing, leaves the newborn unprotected during the hours when perinatal transmission is prevented.

A nurse performs developmental screening at a 9-month well-child visit. Which finding should the nurse report to the provider for further evaluation?

• a.The infant cries when a stranger holds her.
• b.The infant cannot sit without support.✓
• c.The infant is not yet walking across the room.
• d.The infant has not said a clear first word yet.

Sitting without support is a CDC movement milestone for 9 months, so an infant who cannot do it needs further evaluation. Being shy or fearful with strangers is an expected 9-month social milestone, and walking independently and saying a first special name are milestones for later ages, so their absence at 9 months is not a red flag.

A nurse is counseling the parent of a 7-month-old who has started eating solid foods. Which statement by the parent requires correction by the nurse?

• a.I give him soft cooked vegetables cut into small pieces.
• b.I keep offering breast milk along with his new solid foods.
• c.I offer him iron-fortified cereal thinned with breast milk.
• d.I dip his pacifier in honey when he is fussy about teething.✓

Honey, including honey placed on a pacifier, can contain Clostridium botulinum spores and must not be given to a child younger than 1 year because of the risk of infant botulism. Iron-fortified cereal, soft cooked vegetables in small pieces, and continued breast milk alongside complementary foods are all appropriate at 7 months.

The parent of a healthy 4-year-old who weighs 40 pounds tells the nurse she plans to move the child from a forward-facing car seat to a booster seat this week. Which response by the nurse is correct?

• a.Move her to a booster now, because 4 years is the age for a booster seat
• b.Keep her in the harnessed seat until she outgrows its height or weight limit✓
• c.Move her to a booster in the front seat so the shoulder belt fits her
• d.Move her back to a rear-facing seat until she turns 5 years of age

CDC guidance is to keep a child in a forward-facing seat with a harness and top tether until the child reaches the manufacturer's maximum height or weight limit, which for most children is well past age 4, so age alone does not trigger the move to a booster. Children stay buckled in the back seat until age 13, so moving her to the front seat is not an option.

The parent of a healthy 2-year-old tells the nurse she worries her son is behind the other children at his daycare. Which behavior should the nurse identify as an expected milestone for his age?

• a.He names several colors when shown a set of blocks
• b.He puts two words together, such as saying 'more milk'✓
• c.He tells a stranger his own first name when asked
• d.He draws a person with three or more body parts

Saying at least two words together, such as 'more milk,' is a CDC language milestone for 2 years, so this child is on track. Giving one's own first name on request belongs to the 3-year list, and naming colors and drawing a person with three or more body parts are 4-year milestones, so their absence at 2 years is expected.

An 8-year-old is hospitalized for two weeks in traction after a femur fracture. Which nursing action best supports this child's psychosocial development?

• a.Limit visits from classmates so that he can rest and recover faster
• b.Encourage his parents to make his daily care choices for him for now
• c.Arrange schoolwork and let him finish projects he can show others✓
• d.Offer a choice of two pajama colors to give him a sense of control

A school-age child is in Erikson's industry versus inferiority stage, so chances to complete tasks and be recognized for accomplishments protect self-esteem during a long admission. Simple either-or choices are what a toddler working on autonomy needs, and removing peer contact and decision making both deepen a sense of inferiority.

A school nurse is planning a health education session for parents of fifth graders. Which physical activity recommendation should the nurse present for children this age?

• a.150 minutes of moderate activity spread across the whole week
• b.20 minutes of vigorous activity on three or four days each week
• c.30 minutes of moderate activity on at least five days each week
• d.60 minutes or more of moderate-to-vigorous activity every day✓

CDC guidance for ages 6 through 17 is at least 60 minutes of moderate-to-vigorous physical activity daily, including vigorous, muscle-strengthening, and bone-strengthening activity on at least 3 of those days. The 150-minutes-per-week figure is the adult aerobic target and understates what school-age children need.

A 38-year-old client already walks briskly for 30 minutes on five days each week. Which addition should the nurse recommend so the client meets the physical activity guidelines for adults?

• a.Muscle-strengthening activity on at least two days each week✓
• b.Balance training on at least three days of each week
• c.An additional 150 minutes of brisk walking spread over the week
• d.Static stretching before and after each walking session

CDC guidance for adults is 150 minutes of moderate-intensity aerobic activity per week plus muscle-strengthening activity on 2 or more days a week; this client already meets the aerobic target and is missing only the strengthening component. Balance training is emphasized for older adults at risk of falling, and stretching does not count toward either requirement.

During a routine visit, a 34-year-old client screens positive for risky drinking on a validated alcohol screening tool and has no signs of alcohol dependence. Which action should the nurse take?

• a.Refer the client directly to an inpatient medical detoxification unit
• b.Reassure the client that a daily drink carries no health risk
• c.Provide a brief behavioral counseling intervention about drinking✓
• d.Repeat the screening tool at the client's visit in twelve months

USPSTF recommends screening adults 18 and older for unhealthy alcohol use and providing brief behavioral counseling to those who screen positive for risky or hazardous drinking, which is exactly this client's result. Inpatient detoxification is aimed at withdrawal risk in dependence, and postponing the conversation for a year forgoes the intervention the screening was done to trigger.

A nurse is planning care for a 74-year-old who lives alone and has fallen twice in the past year. Which intervention has the strongest preventive evidence for this client?

• a.Set up a bed alarm in the client's home each night
• b.Advise the client to limit walking outside the home
• c.Enroll the client in a supervised exercise program✓
• d.Arrange a weekly telephone check from clinic staff

USPSTF gives exercise interventions a B recommendation to prevent falls in community-dwelling adults 65 years or older who are at increased risk, and two falls in the past year establishes that risk. Restricting walking is counterproductive because deconditioning raises fall risk, while alarms and telephone checks may detect a fall but do nothing to prevent one.

A home health nurse visits an 80-year-old who walks with a rolling walker and reports poor night vision. Which finding in the home should the nurse address first?

• a.A pill organizer refilled by a neighbor each Sunday
• b.Expired canned goods stored in a kitchen cupboard
• c.Loose throw rugs along the hallway to the bathroom✓
• d.A cordless telephone kept in the living room only

Loose rugs in the path a walker must cross are the immediate fall hazard for a client with an assistive device and poor night vision, and removing them is a first-line home modification alongside better lighting and clutter reduction. The other findings deserve follow-up, but none of them is likely to put this client on the floor tonight.

A 41-year-old client with no personal or family history of breast cancer asks when she should begin screening mammograms. Which response by the nurse reflects current USPSTF guidance?

• a.Begin now and repeat the mammogram every two years through age 74✓
• b.Begin at age 50 and repeat the mammogram every two years to 74
• c.Begin at age 45 and repeat the mammogram every year until age 54
• d.Begin screening now and repeat the mammogram every year to age 74

USPSTF recommends biennial screening mammography for women aged 40 to 74 years, so an average-risk 41-year-old should start now and be screened every other year. Annual screening and a start age of 50 reflect other organizations' guidance or the superseded 2016 USPSTF statement rather than the current recommendation.

A nurse is reviewing preventive services for a 4-year-old at a well-child visit. Which screening does USPSTF recommend for a child of this age?

• a.Vision screening to detect amblyopia and its risk factors✓
• b.Depression screening with a standardized adolescent tool
• c.Scoliosis screening of the spine in a forward bend position
• d.Hearing screening repeated at every visit from age 3 to 5

USPSTF recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors, and concludes evidence is insufficient for children younger than 3. Depression screening is the tempting choice, but its B recommendation begins at age 12, and neither repeated preschool hearing screening nor scoliosis screening at this age is a USPSTF recommendation.

A nurse is setting up preventive services at a school-based health center. For which group does USPSTF recommend routine screening for major depressive disorder?

• a.Students of any age each school year
• b.Children 8 to 11 years of age
• c.Adolescents with a prior diagnosis only
• d.Adolescents 12 to 18 years of age✓

USPSTF gives a B recommendation to screening adolescents 12 to 18 years for major depressive disorder and an I statement for children 11 years and younger, where the evidence is insufficient. Screening is intended for students without a recognized diagnosis, so limiting it to those already diagnosed would defeat its purpose.

A client at her first prenatal visit reports regular 28-day cycles and states that her last menstrual period began on August 1, 2026 and that the flow lasted five days. Using Naegele's rule, which estimated date of delivery should the nurse record?

• a.May 1, 2027
• b.May 8, 2027✓
• c.May 12, 2027
• d.April 24, 2027

Naegele's rule is applied to the first day of the last menstrual period: August 1, 2026 plus 1 year and 7 days, minus 3 months, gives May 8, 2027, which is also the 280th day after that date. Counting from the last day of the flow rather than the first day, subtracting the 7 days instead of adding them, or leaving the 7 days out altogether are the three errors that produce the other dates.

A community health nurse visits a family whose 2-year-old lives in a house built in 1955 that is being repainted. Which teaching addresses this child's greatest environmental risk?

• a.Keep the child away from paint chips and dust during the work✓
• b.Wash the child's hands after outdoor play in the fenced yard
• c.Give the child a calcium supplement during the renovation work
• d.Keep the child's bedroom window open while the work is done

Paint in a home built before 1978 should be assumed to contain lead, and lead-contaminated paint chips and dust generated during renovation are the major source of childhood lead exposure, so keeping a child younger than 6 out of the work area is the priority teaching. Opening a window does not control settled dust, and no supplement substitutes for removing the exposure itself.

A 54-year-old client waiting for breast biopsy results tells the nurse, 'I keep imagining the worst thing they could tell me.' Which response by the nurse is therapeutic?

• a.Tell me more about what you have imagined.✓
• b.Try not to dwell on it before you know.
• c.Has your family arranged a ride home for you?
• d.Why let yourself think that way now?

Inviting the client to say more about the specific fear is an open, exploring response that keeps her talking about her own experience. Telling her not to dwell on it minimizes the fear, 'why let yourself think that way' asks her to justify a feeling, and the question about a ride home changes the subject.

A client whose permanent colostomy was created four days ago turns away during the pouch change and says, 'My wife is not going to want to be near me now.' Which response by the nurse is therapeutic?

• a.Your wife has visited every day, so she clearly still cares.
• b.You sound worried about how your wife will see you.✓
• c.Are you able to look at the stoma without feeling upset?
• d.Ask your wife to join the next teaching session.

Restating the client's concern as a feeling is reflection, and it invites him to expand on the fear he just raised. Pointing to the visits is false reassurance, telling him to bring his wife to teaching is advice rather than exploration, and a yes-or-no question about looking at the stoma limits him to one word.

A nurse manager listens while a newly hired nurse interviews a client who stopped taking a prescribed antihypertensive. Which statement by the new nurse requires follow-up by the manager?

• a.Walk me through a usual day with your medicines.
• b.Why did you decide to stop taking the medication?✓
• c.Tell me what you noticed after your last refill.
• d.What was going on around the time that you stopped?

A 'why' question asks the client to justify a decision and typically produces defensiveness or silence instead of history, so it is the statement the manager must address. The other three are open invitations that gather the same information without putting the client on the defensive.

A home health nurse visits an 84-year-old client who lives with an adult child. Which finding most strongly suggests neglect?

• a.The client keeps a cane beside the recliner and walks slowly.
• b.The client is dehydrated and has a stage 3 sacral pressure injury.✓
• c.The client has a bruise on the shin from bumping a coffee table.
• d.The client's child manages the mail and pays the household bills.

Neglect is the failure to meet an older adult's basic needs for food, water, hygiene, and medical care, and dehydration together with an advanced pressure injury shows those needs went unmet. Handling a parent's mail is not by itself financial exploitation, and a shin bruise with a matching explanation or a cane in regular use are ordinary findings.

An emergency department nurse cares for a 3-year-old who has spiral fractures of both forearms, and the caregiver's account of the injury changes twice during the visit. What should the nurse do?

• a.Wait for the radiologist to confirm the fracture pattern.
• b.Confront the caregiver about the changing account.
• c.Collect photographs of the injuries before reporting.
• d.Report the suspicion to child protective services.✓

A nurse is a mandated reporter and the legal threshold is reasonable suspicion, so the report is made now; confirming abuse is the investigating agency's job, not the nurse's. Gathering photographs or waiting for a radiology reading builds a case the nurse is not required to build and delays a report the nurse must personally make, and confronting the caregiver can place the child at greater risk.

A clinic nurse suspects intimate partner violence in a 29-year-old client whose partner answers every question for her and will not leave the room. Which action should the nurse take first?

• a.Ask the partner to describe how the injuries happened.
• b.Give the client a shelter brochure to take home.
• c.Interview the client alone in a private room.✓
• d.Document that the partner appears to be controlling.

Screening only produces a truthful answer when it happens in a safe, private setting, so separating the client from the partner comes before any other step. A brochure carried home can be found by the partner and increase danger, and questioning the partner or charting an impression never obtains the client's own account.

A client hospitalized for pancreatitis reports the last alcoholic drink was three days ago. The client is now disoriented to place, grabbing at objects that are not there, temperature 38.4 C (101.1 F), heart rate 128. Which action should the nurse take first?

• a.Apply soft wrist restraints to stop the grabbing.
• b.Dim the lights and let the client rest undisturbed.
• c.Reorient the client and recheck the vital signs in an hour.
• d.Notify the provider of alcohol withdrawal delirium.✓

Disorientation with hallucinations, fever, and tachycardia appearing more than 48 hours after the last drink describes delirium tremens, which is treated urgently with benzodiazepines and carries mortality up to about 37% when untreated, so the provider is told now. Reorienting and rechecking in an hour delays that treatment, and darkness or restraints address neither the autonomic instability nor its cause.

A client with long-standing alcohol use disorder is admitted with confusion, nystagmus, and an unsteady gait. Orders include IV thiamine and IV dextrose 5% in water. Which action by the nurse is correct?

• a.Ask the provider to switch to oral thiamine.
• b.Hold the thiamine until the gait is retested.
• c.Start the dextrose first to lift the confusion.
• d.Give the thiamine before the dextrose.✓

Confusion, abnormal eye movements, and ataxia are the classic triad of Wernicke encephalopathy from thiamine deficiency, and glucose oxidation consumes the thiamine that remains, so parenteral thiamine goes in first. Delaying it for another gait check or switching to an oral dose delays the only treatment that prevents the permanent memory loss of Korsakoff syndrome, which follows in about 80% of untreated survivors.

Fourteen hours after admission a client has dilated pupils, runny nose, gooseflesh, repeated yawning, abdominal cramping, and three loose stools. Which condition do these findings indicate?

• a.Anticholinergic toxicity
• b.Neuroleptic malignant syndrome
• c.Opioid overdose toxicity
• d.Opioid withdrawal syndrome✓

Dilated pupils with rhinorrhea, piloerection, yawning, cramping, and diarrhea are the autonomic and gastrointestinal signs scored on the Clinical Opiate Withdrawal Scale. Opioid toxicity produces the opposite pupil finding, pinpoint pupils with respiratory depression, and anticholinergic toxicity dilates pupils but dries secretions and slows the gut instead of causing rhinorrhea and diarrhea.

A nurse screens a 38-year-old male client for risky alcohol use at a community clinic. Which report by the client meets the definition of binge drinking and calls for a fuller assessment?

• a.Six beers within three hours at a Saturday cookout✓
• b.One beer with dinner on most evenings of the week
• c.Two glasses of wine on Friday and two more on Sunday
• d.Three beers spread across an entire weekend camping trip

The CDC defines binge drinking as five or more drinks for a man on a single occasion, so six beers in three hours is a positive screen and warrants a fuller assessment of the client's drinking. One beer with dinner most evenings stays within the moderate-drinking limit of two drinks in a day for men and is not a binge episode.

A client with moderate Alzheimer disease becomes upset at the dinner table and insists she must leave to pick up her children from school. Which response by the nurse is most appropriate?

• a.Ask her why she believes school is letting out right now.
• b.Explain that her children are grown adults with families.
• c.Tell her to sit down and finish the meal before leaving.
• d.Acknowledge her worry and walk with her down the hall.✓

Guidance for dementia care is to stay calm, avoid arguing or correcting, and redirect, because the person cannot reason her way out of the belief and being corrected increases distress. Telling her the children are grown argues with the illness, a 'why' question demands reasoning she no longer has, and a command escalates the agitation.

A 19-year-old admitted with anorexia nervosa and a body mass index of 13 begins nutritional rehabilitation. Which laboratory value should the nurse monitor most closely during the first 72 hours?

• a.Serum bilirubin level
• b.Serum amylase level
• c.Serum uric acid level
• d.Serum phosphorus level✓

Hypophosphatemia is the hallmark of refeeding syndrome: reintroduced carbohydrate triggers insulin release that drives phosphate into cells, and the resulting deficit can cause cardiac and respiratory failure. High-risk clients have phosphorus checked before feeding and about every 12 hours for the first three days, while bilirubin, uric acid, and amylase do not track this risk.

During a screening on a medical unit, a client states a plan to overdose on the bottle of sleeping pills in the bag at the bedside. Which action should the nurse take first?

• a.Place the client on hourly safety checks.
• b.Schedule a psychiatric consult for morning.
• c.Ask the client to sign a no-harm contract.
• d.Stay with the client and secure the pills.✓

A client with a specific plan and the means within reach cannot be left alone; continuous observation combined with removing the means is the immediate intervention, and the urgent mental health evaluation follows. Hourly checks leave unwatched intervals, a morning consult delays an evaluation needed now, and no-harm contracts have not been shown to keep clients safe.

A client assessed as high risk for suicide is admitted to a medical unit that is not ligature resistant and is awaiting transfer to a behavioral health facility. Which action best reduces the environmental risk?

• a.Remove cords, belts, and glass items from the room.✓
• b.Let the family keep personal belongings at the bedside.
• c.Close the door so the client has a quiet space to rest.
• d.Assign the room farthest from the nurses' station.

In a setting that is not ligature resistant the expectation is an environmental risk assessment, removal of objects that could be used for self-harm, and continuous monitoring in a safe location while the client waits for transfer. A distant room and a closed door both reduce observation, and leaving belongings at the bedside leaves the means available.

A nurse meets with a client in the emergency department two hours after the client's home and belongings were destroyed by a fire. The client is tearful and says she does not know what to do next. Which nursing action reflects crisis intervention?

• a.Explore how losses in her childhood shaped this reaction
• b.Help her decide where she will sleep for two nights✓
• c.Begin insight-oriented therapy to change her personality
• d.Postpone planning until she meets a therapist next week

Crisis intervention is short-term work that steadies the client and returns her toward her baseline, so helping her settle a concrete, immediate problem such as where she will sleep tonight is the action that fits. Exploring childhood losses is insight-oriented work belonging to longer-term therapy and does nothing about the practical problem she faces in the next few hours.

A nurse is planning care for a client who has told the admitting nurse that a religious observance important to the client falls during this hospital stay. Which action best incorporates the client's beliefs into the plan of care?

• a.Ask the client which practices to include this week.✓
• b.Ask a relative what the client's community usually does.
• c.Consult a reference describing that faith's dietary rules.
• d.Follow the unit's standard plan for clients of that faith.

People differ within any religious or cultural group in which practices they keep and how strictly, so the client is the only reliable source and asking directly is what individualizes the plan. A standard plan for a faith, a relative's account, and a reference book each substitute an assumption about the group for this client's stated preference.

The adult children of a dying client sit silently at the bedside because their father no longer responds to them. Which instruction should the nurse give the family?

• a.Wait for the chaplain before you say your goodbyes.
• b.Step out until he shows a response to your voices.
• c.Talk to your father as though he can still hear you.✓
• d.Discuss his care in the hallway where he cannot hear.

Families are encouraged to speak to a dying person as if the person can hear them, because awareness of others may persist after responsiveness is lost, and voice, touch, and presence are the comfort measures still available. Leaving the room or waiting for someone else removes the family at the point their presence matters most.

A hospice client who is close to death has loud, wet-sounding respirations. The spouse asks whether the client is drowning. Which nursing action is most appropriate?

• a.Suction the oropharynx deeply whenever the sound returns.
• b.Reposition the client and explain that the sound is expected.✓
• c.Seat the spouse in the hallway until the sound settles.
• d.Increase the intravenous fluid rate to thin the secretions.

Secretions pooling in the airway near death do not appear to distress the client but are frightening to the family, so repositioning plus a plain explanation is the intervention; drug trials for this symptom have been negative. Deep suctioning is traumatic and the sound returns, and extra intravenous fluid in the final days increases the secretions.

Three weeks after her husband's death, a client tells the nurse she cries in waves that pass after about half an hour and that her sleep is broken. She is eating normally and has returned to work. Which action is appropriate?

• a.Tell her the crying should have stopped by now.
• b.Request an antidepressant prescription for the client.
• c.Acknowledge these as usual features of early grief.✓
• d.Refer her for prolonged grief disorder treatment.

Waves of intense sadness lasting twenty to thirty minutes, disturbed sleep, and yearning are ordinary in the first weeks of bereavement and generally ease over the following months, so the nurse normalizes and supports. Prolonged grief disorder is diagnosed when impairing grief persists roughly a year after the death, and antidepressants alone have little effect on grief intensity.