NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 2 of 5
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
Correct Answer: B
Rationale: The infant will be at risk for hypoglycemia because of excess insulin production.
Question 3 of 5
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
Correct Answer: B
Rationale: This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. Sexual infantilism is characteristic of this syndrome. Gynecomastia is a symptom in Klinefelter's syndrome.
Question 4 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 5 of 5
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
Correct Answer: C
Rationale: The client will have minimal difficulty swallowing after a vertical partial laryngectomy, indicating effective preoperative teaching. Special swallowing training is typically required for supraglottic (horizontal partial) laryngectomy, not vertical. Voice quality will be altered, and radical neck dissection is associated with total laryngectomy.