NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
Question 2 of 5
A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:
Correct Answer: C
Rationale: Bulimia is characterized by binge eating followed by purging, such as self-induced vomiting, leading to significant weight loss.
Question 3 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 4 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 5 of 5
As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:
Correct Answer: C
Rationale: An enlarged penis is not a sign of chlamydia. Secondary lymphadenitis is a complication of lymphogranuloma venereum. Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. Hepatomegaly is not a complication.