NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 2 of 5
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
Correct Answer: C
Rationale: Bradycardia is an expected assessment during the postpartum period. Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. A return of rubra after the serosa period may indicate a postpartal complication. Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
Question 3 of 5
The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:
Correct Answer: B
Rationale: Asking 'why' questions may put the child on the defensive and may not elicit useful information, especially in a young child who may struggle to articulate reasons. This approach is open-ended and encourages the child to describe her experiences in a non-confrontational way, which may reveal underlying issues while building trust. This question is too specific and may feel confrontational, potentially causing the child to shut down. While encouraging expression of feelings is appropriate, it is less specific and may not help uncover the specific event or change that led to her refusal to attend.
Question 4 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 5 of 5
A common complaint of the client with an abdominal aortic aneurysm is:
Correct Answer: D
Rationale: A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.