NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected meningitis. Which of the following findings would support this diagnosis? Select all that apply.
Correct Answer: A, B, D
Rationale: Nuchal rigidity, positive Kernig's sign, and photophobia are classic signs of meningitis due to meningeal irritation.
Question 2 of 5
A 10-year-old child is diagnosed with pediculosis. The mother is concerned about the spread of the lice to children who have been in contact with her child. The nurse should instruct the mother to have her child avoid:
Correct Answer: C
Rationale: Sharing batting helmets can spread lice through direct head-to-head contact or shared items, unlike the other activities.
Question 3 of 5
A client with a history of schizophrenia is prescribed paliperidone (Invega). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Paliperidone can cause hyperprolactinemia, leading to symptoms like galactorrhea.
Question 4 of 5
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension, requiring monitoring.
Question 5 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.