Questions 158

NCLEX-RN

NCLEX-RN Test Bank

NCLEX-RN Exam Questions

Question 1 of 5

A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

Correct Answer: D

Rationale: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.

Question 2 of 5

Prior to an amniocentesis, a fetal ultrasound is done in order to:

Correct Answer: C

Rationale: Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus.

Question 3 of 5

The nurse is evaluating the laboratory value results of a client after a craniotomy for a pituitary tumor. Which values cause the nurse to suspect a diabetes insipidus complication?

Question Image

Correct Answer: A, B

Rationale: Diabetes insipidus causes dilute urine (low specific gravity,
A) and hypernatremia (158 mEq/L,
B) from excessive water loss. Potassium (
C), hemoglobin (
D), and chloride (E) are normal and unrelated.

Question 4 of 5

A client with a history of rheumatoid arthritis is admitted with complaints of fatigue. The nurse should give priority to:

Correct Answer: A

Rationale: Fatigue in rheumatoid arthritis may indicate anemia of chronic disease, so monitoring for anemia is the priority.

Question 5 of 5

A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

Correct Answer: D

Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

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