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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

Correct Answer: C

Rationale: Ashley's symptoms, including confusion, dizziness, nausea, rapid pulse, and hyperventilation, indicate severe anxiety, characterized by somatic symptoms and impaired problem-solving. Mild or moderate anxiety would present with less intense symptoms, and panic would involve loss of reality. Psychosocial Integrity

Extract:

The client is taking Aminophylline.


Question 2 of 5

The nurse knows that the client is having problem if she observes that the client is:

Correct Answer: B

Rationale: Restlessness is a sign of aminophylline toxicity, indicating a need for intervention.

Extract:


Question 3 of 5

During morning rounds, the nurse notices blood spots on the pillowcase of a child with acute lymphoid leukemia. The nurse should be most concerned about the client's:

Correct Answer: C

Rationale: Blood spots suggest bleeding, likely due to low platelets (thrombocytopenia) in acute lymphoid leukemia, so C is correct. Red blood cell count , white blood cell count , and reticulocyte count are less directly related to bleeding.

Extract:

A male, Hispanic client with history of excessive 'alcohol-drinking', was admitted with a diagnosis of recurrent pancreatitis. On admission, the client was complaining of unbearable pain.


Question 4 of 5

The nurse

Correct Answer: A

Rationale: Demerol is preferred for pancreatitis pain to avoid sphincter of Oddi spasm associated with morphine.

Extract:

During the second phase of bum recovery, the nurse anticipates that the client will exhibit


Question 5 of 5

high serum potassium level.

Correct Answer: B

Rationale: An increased urinary output is a sign of adequate hydration during the second phase of burn recovery.

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