NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Which of the following interventions will be useful for the patient with Alzheimer's dementia who exhibits prosopagnosia?
Correct Answer: B
Rationale: Prosopagnosia is the inability to recognize faces. Labeled pictures of family and friends can help the patient identify familiar people improving social interaction and reducing confusion. The other options do not directly address face recognition.
Question 2 of 5
A client with a history of liver cirrhosis is admitted with ascites. Which intervention would the nurse expect to implement?
Correct Answer: A
Rationale: Furosemide reduces fluid overload in ascites by promoting diuresis. Increasing fluids (
B), heating pads (
C), and high-sodium diets (
D) worsen ascites.
Question 3 of 5
The client at 28 weeks gestation is admitted with a diagnosis of preterm labor. The physician orders a non-stress test. The nurse should explain to the client that this test is used to:
Correct Answer: C
Rationale: A non-stress test (NST) evaluates fetal well-being by monitoring fetal heart rate accelerations in response to movement. It does not assess lung maturity contractions or maternal hypertension.
Question 4 of 5
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:
Correct Answer: A
Rationale: Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
Question 5 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.