NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
Correct Answer: C
Rationale: Head measurement (e.g., head circumference) is the most objective for hydrocephalus, directly assessing skull enlargement. Anorexia (
A), vomiting (
B), and temperature (
D) are subjective or less specific.
Question 2 of 5
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
Correct Answer: C
Rationale: The bleeding ulcer can be life-threatening, emphasizing the need to address the physical threat posed by the psychophysiological disorder.
Question 3 of 5
The nurse is performing an assessment on an elderly client who had a total hip repair this morning. Which assessment finding indicates that the patient is in pain?
Correct Answer: D
Rationale: Grimacing during care is a direct behavioral indicator of pain, common in post-operative patients. Elevated blood pressure, inability to concentrate, or dilated pupils may have other causes and are less specific.
Question 4 of 5
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?
Correct Answer: C
Rationale: At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
Question 5 of 5
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
Correct Answer: A
Rationale: This answer is correct. If the cause is removed, the delirious client will recover completely. This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.