NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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 2 of 5
The client is admitted with a diagnosis of pericarditis. Which assessment finding is most characteristic?
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by sitting forward, reducing pressure on the inflamed pericardium. Bradycardia, edema, and muffled sounds are less specific or indicate complications like tamponade.
Question 3 of 5
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, 'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:
Correct Answer: C
Rationale: Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
Question 4 of 5
The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?
Correct Answer: B
Rationale: Exercise lowers blood sugar, so a snack may be needed to maintain appropriate glucose levels. The other options are incorrect as they increase the risk of hypoglycemia or are factually inaccurate.
Question 5 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.