NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
Question 2 of 5
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
Correct Answer: D
Rationale: The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.
Question 3 of 5
For the client with a substance abuse problem, which of the following would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs?
Correct Answer: B
Rationale: Group sessions provide peer support and shared experiences, highly effective for addressing feelings related to substance abuse.
Question 4 of 5
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
Question 5 of 5
The nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
Correct Answer: A
Rationale: Nuchal rigidity is a critical sign of meningitis, indicating meningeal irritation and requiring immediate medical intervention to prevent complications.