NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A female client with major depression stated that 'life is hopeless and not worth living.' The nurse should place highest priority on which of the following questions?
Correct Answer: B
Rationale: Maintenance of the client's life is the priority; assessment of suicidal intent is imperative.
Question 2 of 5
The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:
Correct Answer: A
Rationale: Novolin is a short-acting insulin. (B,
C) NPH and Lente are intermediate-acting insulins. Protamine zinc insulin is a long-acting insulin preparation.
Question 3 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 4 of 5
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
Correct Answer: A
Rationale: Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. Most antipsychotic drugs are chemically similar and will produce the same side effects.
Question 5 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.