NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A client who served three tours of duty in Afghanistan has been diagnosed with posttraumatic stress disorder (PTSD). Which of the following signs and symptoms does the nurse expect the client to exhibit? Select all that apply.
Correct Answer: A,B,C,E
Rationale: PTSD symptoms include recurring flashbacks (
A), detachment (
B), anger (
C), and nightmares (E). Hyperacute memory (
D) is not typical, and excessive sleeping (F) is less common than insomnia in PTSD.
Question 2 of 5
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury patients. Assessing and relieving the bladder is the priority after elevating the bed.
Question 3 of 5
A home health nurse has four clients assigned for morning visits. The nurse should give priority to visiting the client with:
Correct Answer: B
Rationale: Frothy sputum in congestive heart failure suggests pulmonary edema, a life-threatening condition requiring immediate attention.
Question 4 of 5
The client who is 2 weeks post-burn with a 40% deep partial-thickness injury still has open wounds. The nurse's assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea stools. What problem does the nurse most likely suspect?
Correct Answer: C
Rationale: Hypothermia, hypotension, and diarrhea suggest systemic gram-negative infection, likely sepsis, due to bacterial translocation from open wounds or the gut in a burn patient.
Question 5 of 5
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
Correct Answer: A
Rationale: Leaving the stethoscope in the room prevents MRSA transmission, as it avoids contaminating other areas or clients.