NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
Correct Answer: D
Rationale: Transient depression manifests as sadness or the 'blues' as seen with everyday disappointments and is not necessarily dysfunctional. Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression.
Question 2 of 5
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.
Question 3 of 5
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (
B), nausea (
C), and hyperactivity (
D) are not associated with clopidogrel.
Question 4 of 5
Which nursing intervention would be of highest priority when caring for a patient admitted in sickle cell vaso-occlusive crisis?
Correct Answer: D
Rationale: In sickle cell vaso-occlusive crisis severe pain results from blocked blood vessels. Administering pain medication is the highest priority to relieve acute discomfort and improve patient comfort. While IV fluids and oxygen are important pain management is the most urgent need.
Question 5 of 5
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
Correct Answer: C
Rationale: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.