NCLEX-PN
2024 Nclex Questions Questions
Question 1 of 5
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
Correct Answer: C
Rationale: Given the history of childhood sexual abuse and the presenting symptoms of difficulty concentrating, insomnia, and nightmares, the nurse should assess the client for post-traumatic stress disorder (PTS
D). Childhood sexual abuse is strongly associated with adult-onset depression and an increased risk for PTSD. Individuals with PTSD may exhibit re-experiencing symptoms such as flashbacks, nightmares, and heightened reactions to trauma triggers. They may also display emotional numbing, avoidance behaviors, and increased arousal symptoms like difficulty sleeping and hypervigilance. Generalized anxiety disorder (
Choice
A) is characterized by excessive worry and anxiety about various events or activities, not necessarily tied to a specific trauma. Schizophrenia (
Choice
B) is a severe mental disorder characterized by distortions in thinking, perception, emotions, and behavior, unrelated to the traumatic event described. Bipolar disorder (
Choice
D) involves mood swings between depressive and manic episodes, and its symptoms differ from those typically seen in PTSD.
Question 2 of 5
The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
Correct Answer: C
Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.
Question 3 of 5
When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:
Correct Answer: A
Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock.
Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock.
Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock.
Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.
Question 4 of 5
A mother has just given birth to a baby who died soon after. The mother has been crying and states, "I can't believe this has happened to me. I did everything right during this pregnancy."? How should the nurse respond to this mother?
Correct Answer: D
Rationale: Perinatal loss is a significant tragedy for parents, and it is crucial to provide sensitive and compassionate care. When a mother expresses her disbelief and feelings of doing everything right during the pregnancy, it is important for the nurse to acknowledge her pain and allow her to grieve in her way. Telling her that she did nothing wrong and it was God's will (
Choice
A) may not be comforting and can come across as dismissive of her feelings. Suggesting she can have another baby (
Choice
B) is insensitive and overlooks the grief she is experiencing for the current loss. Telling her that her behavior is not going to solve anything (
Choice
C) is invalidating her emotions and not supportive in this situation.
Therefore, the best approach is to support her in her mourning process by respecting her feelings and allowing her to express her grief as she sees fit.
Question 5 of 5
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.