NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a fractured ankle who is in a cast. The client complains of numbness and tingling. The nurse should:
Correct Answer: C
Rationale: Numbness and tingling suggest neurovascular compromise (e.g., compartment syndrome), requiring immediate physician notification. Ice, elevation, and massage are insufficient.
Question 2 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.
Question 3 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 4 of 5
The client with a cervical dilation of 8cm suddenly becomes short of breath,cyanotic and hypotensive. The nurse should suspect which of the following complications?
Correct Answer: A
Rationale: Amniotic fluid embolus is a rare but life-threatening complication characterized by sudden dyspnea cyanosis and hypotension due to amniotic fluid entering the maternal circulation. These symptoms are not typical of transition phase abruption or cord prolapse.
Question 5 of 5
The nurse is caring for a client with a history of a fractured pelvis who is in skeletal traction. The nurse should:
Correct Answer: D
Rationale: Monitoring for infection at pin sites prevents osteomyelitis in skeletal traction. Turning is limited, weights must hang freely, and lotion is unnecessary.