NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.
Question 2 of 5
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
Correct Answer: B
Rationale: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.
Question 3 of 5
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Correct Answer: B
Rationale: Offering a pacifier can disrupt the surgical repair of a cleft lip by placing pressure on the suture line. Holding, providing a mobile, and offering sterile water are safe and comforting.
Question 4 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 5 of 5
The nurse is caring for a client post-appendectomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: A temperature of 101.5°F post-appendectomy suggests infection (e.g., abscess), requiring immediate intervention. Pain (
A), serous drainage (
C), and absent bowel sounds (
D) are expected initially.