NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
Correct Answer: B
Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
Question 2 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.
Question 3 of 5
The nurse is preparing to administer a dose of lorazepam (Ativan) for anxiety. Which assessment is most important before administration?
Correct Answer: B
Rationale: Lorazepam, a benzodiazepine, can cause respiratory depression, so assessing respiratory rate is critical before administration. Other vital signs are monitored but are less specific.
Question 4 of 5
The nurse is caring for a client with a history of a seizure disorder who is receiving Valproic acid (Depakote). The nurse should monitor the client for:
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and weight loss are not primary side effects.
Question 5 of 5
A client with a history of heart failure is admitted with complaints of edema. The nurse should give priority to:
Correct Answer: A
Rationale: Diuretics reduce edema in heart failure, improving fluid balance and symptoms.