NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
Question 2 of 5
A 24-year-old graduate student recognizes that he has a phobia傳He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
Correct Answer: A
Rationale: This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
Question 3 of 5
Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?
Correct Answer: B
Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.
Question 4 of 5
The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?
Correct Answer: A,C,D,E
Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.
Question 5 of 5
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?
Correct Answer: B
Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.