NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
Question 2 of 5
A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.
Question 3 of 5
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
Question 4 of 5
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
Question 5 of 5
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
Correct Answer: B
Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the client's formulation of a plan for the suicide attempt. Although all of the choices are correct, preventing self-harm is the priority in the context of the suicidal client. Clients with a history of self-harm are greater suicide risks.