NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a seizure disorder who is receiving Valproic acid (Depakote). The nurse should monitor the client for:
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and weight loss are not primary side effects.
Question 2 of 5
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
Correct Answer: B
Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.
Question 3 of 5
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:
Correct Answer: C
Rationale: Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus, leading to intrauterine growth retardation. Alcohol consumption also decreases birth weight.
Question 4 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 5 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.