NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

NCLEX-RN

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NCLEX-RN Exam Practice Questions

Extract:


Question 1 of 5

During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

Correct Answer: A

Rationale: The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. Echopraxia is mimicking the movements of another person. Echolalia is mimicking the speech of another person.

Question 2 of 5

A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

Correct Answer: C

Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.

Question 3 of 5

Which of the following factors affects the accuracy of pulse oximetry readings?

Question Image

Correct Answer: A, B, C

Rationale: Pulse oximetry accuracy is reduced by poor circulation (
A), improper probe placement (
B), and bright lighting (
C). Dark skin (
D) has minimal impact with modern sensors.

Question 4 of 5

The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?

Correct Answer: B

Rationale: A Foley catheter is inserted during cervical radiation implants to keep the bladder empty, reducing radiation exposure. TV/phone use (
A) is allowed, high-fiber diet (
C) is not specific, and excretions (
D) are not radioactive with internal implants.

Question 5 of 5

During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

Correct Answer: A

Rationale: The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. Echopraxia is mimicking the movements of another person. Echolalia is mimicking the speech of another person.

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