NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A 79-year-old client with Alzheimer's disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client's care:
Correct Answer: A
Rationale: Alzheimer's clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions.
Question 2 of 5
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
Correct Answer: A
Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.
Question 3 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 4 of 5
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, 'I get them whenever I bump into anything.' The nurse would expect to note a decrease in which of the following laboratory tests?
Correct Answer: A
Rationale: Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. Clients with lupus may have a decrease in the hemoglobin level causing anemia. Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.
Question 5 of 5
In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
Correct Answer: B
Rationale: Haloperidol is an antipsychotic medication and may be used until the lithium takes effect.