NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 2 of 5
A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:
Correct Answer: D
Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
Question 3 of 5
Which instruction should be given to the client who has been prescribed a dry powder inhaler for treatment of COPD?
Correct Answer: A, D, E
Rationale: Dry powder inhaler use involves removing the cap and shaking (
A), placing the mouthpiece in the mouth (
D), and weekly dry cleaning (E). Rinsing (
B) risks moisture damage, and spacers (
C) are typically for metered-dose inhalers.
Question 4 of 5
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
Correct Answer: A
Rationale: Endemic goiter results from iodine deficiency, often in areas with iodine-depleted soil, leading to insufficient thyroid hormone production.
Question 5 of 5
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
Correct Answer: C
Rationale: Pericarditis can cause dyspnea but primarily causes chest pain. Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.