NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they 'suffer and feel lousy' when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client?
Correct Answer: D
Rationale: The client's symptoms of feeling 'lousy' when stopping the drug indicate physical dependence, as the body has adapted to the presence of amphetamines, leading to withdrawal symptoms upon cessation.
Question 2 of 5
Which is a sign of thrombocytopenia?
Correct Answer: A
Rationale: Petechiae, small red or purple spots on the skin, are a hallmark sign of thrombocytopenia due to low platelet counts.
Question 3 of 5
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
Correct Answer: D
Rationale: Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Belt and waist restraints prevent the client from getting up or falling out of bed or off a stretcher but do nothing to limit hand movement. Wrist restraints cause resistance.
Question 4 of 5
The nurse is watching two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse has discussed the parent before about how to handle this situation. The nurse should judge that the teaching has been effective when the parent does which of the following?
Correct Answer: B
Rationale: Ignoring minor verbal arguments allows children to resolve conflicts independently, as previously taught. Forcing handshakes or punishment escalates the situation unnecessarily.
Question 5 of 5
A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, 'I'm having a lot of cramping. This didn't happen when I nursed my first baby,' which of the following would be the nurse's best response?
Correct Answer: D
Rationale: Breast-feeding stimulates oxytocin release, causing uterine contractions and cramping, which is normal and often more noticeable in multiparous women.