NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
Correct Answer: A
Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.
Question 2 of 5
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
Correct Answer: A
Rationale: Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. Most antipsychotic drugs are chemically similar and will produce the same side effects.
Question 3 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 4 of 5
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Correct Answer: C
Rationale: This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. This answer is correct. Manipulative clients must abide by consistent rules. This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
Question 5 of 5
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?
Correct Answer: A
Rationale: A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases.
Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated.