Note: These questions include ones similar to alternative format questions as seen on the NCLEX-RN exam.

A nurse is assessing a 6-year-old Asian child with injuries sustained after “falling from a bicycle.” The child’s injuries are inconsistent with the provided history. He is brought in by his mother, a physician, who also has resolving facial injuries. When questioned, the mother cannot recall how she received her injuries. Which of the following factors supports the nurse’s suspicion of child abuse?

A nurse is caring for a 19-year-old female admitted for psychosis. The patient tells the nurse that she sees numerous people in the room speaking to her. The nurse and the patient are the only two people in the room. Which of the following statements by the nurse would be most appropriate?

A nurse is taking care of an intoxicated male patient who has been involved in a motor vehicle accident. Although not critically injured, the patient refuses to remain on his gurney, continuously gets up to leave the ED, and is unsteady on his feet. The nurse is given a written order by the physician to use wrists restraints on the patient. When the nurse tells the patient this, he refuses. Which of these is the correct action for the nurse to take?

A nurse is caring for a 37-year-old male diabetic patient admitted post operatively below-knee amputation as a result of poor wound healing after a motor vehicle accident. Which of the following comments by the patient indicates ineffective coping with his post-operative recovery?

Select all that apply.

A. “When can I start physical therapy so I learn how to move around again?”
B. “I am going to work with a prosthetics specialist to fit a new lower limb.”
C. “Just order me a wheelchair, it’s not like I’m going to walk with one leg.”
D. “I will ensure that my blood sugars are appropriately managed.”
E. “I don’t want to see my leg. This is just a bad dream.”

A nurse is taking care of a patient who is exhibiting signs of severe stress. Which of these nursing interventions is least helpful for the nurse to use to minimize the patient’s stress in this situation?

A nurse is discussing the diagnosis of a terminal disease with a patient. When the nurse asks the patient about how he is feeling about all of the information she’s giving him, he states,”I don’t think there’s anything wrong with me…I’m not worried at all.” This statement is an example of what kind of defense mechanism?

A nurse sees a 12-year-old female for a well-child visit. The child’s mother is concerned that since a recent car accident, the child wants to co-sleep with the mother and is afraid of the dark. The nurse explains that this is representative of which defense mechanism?

A nurse is caring for a patient who has just undergone a major life-changing event. The patient exhibits signs of near complete detachment from her surroundings and appears disoriented. She expresses thoughts and feelings of being completely overwhelmed by her current situation. When caring for a patient in a crisis such as this, which of the following is the first priority of the nurse?

Which of these interventions are congruent with cultural competence?
Select all that apply.

A. Listen with respect.
B. Integrate caregivers into the patient’s care.
C. Use family members as interpreters for medically sensitive information.
D. Evaluate the effectiveness of the care plan.
E. Project personal views upon patients.

A hospice nurse is caring for a patient who has made the decision to pass away at home. The patient is refusing to eat or drink. During a visit, one of the patient’s adult children asks the following question, “Why is my mom not eating or drinking? Can’t we give her something to help her get her strength back?” Which of these is the most appropriate response to this question?

While caring for a chronically ill, hospitalized male, the nurse notes that he and his wife are often hostile and angry with each other when she visits him. The nurse notes that the patient’s physical, emotional, and mental health is suffering as a result. Which of these is the correct course of action for the nurse to take at this time?

Which of these are stages of grief as described by Elizabeth Kubler-Ross?
Select all that apply.

A. depression
B. elation
C. acceptance
D. anger
E. denial

A newly graduated nursing student accepts a position with a company that provides hospice care. Which of these is the most important thing that this nurse needs to do before he begins this position?

A home health nurse visits a pleasant, independent 89-year-old female. At her appointment, the patient appears confused and agitated and has difficulty answering questions. The patient’s vital signs are normal. Which of the following is the most appropriate nursing action?

A nurse is caring for a hospitalized Hindu client who is served a Salisbury steak dinner. Which of these is the most appropriate action for the nurse to take?

A nurse is caring for four patients on a med/surg floor of a hospital. Based on what the nurse knows about risk factors for sensory and/or perceptual alterations, which of these patients would least likely be at risk of potentially developing this problem?

A nurse is caring for a patient who has limited social contacts and family during her convalescence. The nurse knows that she needs to incorporate support systems into this patient’s care plan. Which of these is a reason for the helpfulness of support systems in a patient’s recovery?

A nurse taking care of a patient needs to have a lengthy discussion about a sensitive aspect of the patient’s care. To have therapeutic communication with this patient, the nurse should do which of these?

A nurse is working at a pregnancy crisis clinic. She is caring for a 15-year-old girl who is there for a pregnancy test. When the nurse gives her the positive result, the girl becomes distraught and seems overwhelmed. The nurse begins to discuss the patient’s situation with her and shares that she too was once an unwed mother at the age of 16. In terms of therapeutic communication, this example most specifically demonstrates which of its essential conditions?

Which of these patients is correctly matched with the proper therapeutic environment?