NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
Question 1 of 5
For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.
Correct Answer: A,C,D
Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.
Extract:
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
Question 2 of 5
Which of the following findings require immediate follow-up? Select all that apply
Correct Answer: A,C,E
Rationale: Chest tightness , palpitations , and shortness of breath suggest a panic attack or cardiac issue, requiring urgent evaluation.
Extract:
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Question 3 of 5
Select to highlight below the 4 findings that require immediate follow up.
| The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. |
| The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. |
| The client's mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. |
| The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog. |
Correct Answer: A,B,C,D
Rationale: Dangerous behavior , delusions with violent intent , paranoid history , and social withdrawal indicate acute psychosis requiring urgent intervention.
Question 4 of 5
Which complication of schizophrenia should the nurse be most concerned about?
Correct Answer: C
Rationale: Self-harm is the most urgent complication due to potential for immediate danger.
Extract:
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
Question 5 of 5
For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism, myocardial infarction, or panic disorder.
| Finding | Hyperthyroidism | Myocardial Infarction | Panic Disorder |
|---|---|---|---|
| Diaphoresis | |||
| Trembling hands | |||
| Heart palpitations | |||
| Shortness of breath |
Correct Answer: A,B,C,D
Rationale: Diaphoresis , palpitations , and shortness of breath occur in all three. Trembling hands are specific to hyperthyroidism and panic disorder.