NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client with SIADH is admitted with severe hyponatremia. Which type of intravenous solution would the nurse expect to be ordered?
Correct Answer: B
Rationale: SIADH causes water retention and severe hyponatremia. Hypertonic 3% sodium chloride is used to correct low sodium levels by drawing water out of cells. Isotonic or hypotonic fluids may worsen hyponatremia and colloids are not indicated.
Question 2 of 5
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
Correct Answer: B
Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
Question 3 of 5
Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:
Correct Answer: A
Rationale: Joints usually remain inflamed and tender until the disease runs its course in <3 weeks. This response does not answer the question of whether she will always be arthritic. This response does not answer the question asked. The disease takes <3 weeks to run its course.
Question 4 of 5
An 82-year-old former restaurant owner walks to the nursing station and states, 'I have to go. The restaurant opens at 11 am.' Which response by the nurse is the most appropriate?
Correct Answer: C
Rationale: This response cuts off communication with the client. It does not address her feelings. Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
Question 5 of 5
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.