NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Question 1 of 5
When a patient refuses to believe a terminal diagnosis, they are exhibiting:
Correct Answer: C
Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice
A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice
B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice
D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.
Question 2 of 5
An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?
Correct Answer: A
Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.
Question 3 of 5
When a patient is standing in anatomical position, where are their feet?
Correct Answer: B
Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference.
Choice A is incorrect because the feet should not be spread open, but rather side by side.
Choice C is incorrect as it does not mention the correct positioning of the feet.
Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.
Question 4 of 5
During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?
Correct Answer: D
Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis.
Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.
Question 5 of 5
What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?
Correct Answer: A
Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.