NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A 12-year-old boy is admitted due to depression and post-trauma response. Child Protective Services reports that the boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
Correct Answer: A, B, C, D, E
Rationale: Incest victims may exhibit sexualized play, aggression, isolation, running away, and truancy as coping mechanisms or trauma responses.
Question 2 of 5
When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include?
Correct Answer: B
Rationale: Febrile seizures typically occur as the fever rises rapidly in young children (usually under age 5), not specifically after immunizations or in older children.
Question 3 of 5
A client with a history of gout is admitted with joint swelling. The nurse should include which of the following in the plan of care?
Correct Answer: C
Rationale: Indomethacin reduces inflammation and pain in acute gout attacks.
Question 4 of 5
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
Correct Answer: A
Rationale: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
Question 5 of 5
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.