NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?
Correct Answer: B
Rationale: Meningitis at six months can cause brain injury, contributing to cerebral palsy, a condition often linked to perinatal or early postnatal neurological damage. Full-term birth, physiologic jaundice, and sore throats are not directly related.
Question 2 of 5
The nurse is caring for a client who is receiving oxytocin for labor induction. The fetal heart rate shows variable decelerations. The nurse’s first action should be to:
Correct Answer: B
Rationale: Variable decelerations suggest umbilical cord compression. Repositioning the client (e.g. to the left side or knee-chest position) may relieve compression and is the first action. Stopping oxytocin or notifying the physician may be needed if repositioning is ineffective.
Question 3 of 5
An 82-year-old former restaurant owner walks to the nursing station and states, 'I have to go. The restaurant opens at 11 am.' Which response by the nurse is the most appropriate?
Correct Answer: C
Rationale: This response cuts off communication with the client. It does not address her feelings. Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
Question 4 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.
Question 5 of 5
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
Correct Answer: A
Rationale: Endemic goiter results from iodine deficiency, often in areas with iodine-depleted soil, leading to insufficient thyroid hormone production.