NCLEX-RN
NCLEX RN Exam Review Answers Questions
Question 1 of 5
The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?
Correct Answer: C
Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.
Question 2 of 5
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
Question 3 of 5
What is a key principle of patient teaching that must take place to ensure patient safety?
Correct Answer: C
Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.
Question 4 of 5
A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?
Correct Answer: B
Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.
Question 5 of 5
As a nursing supervisor in a long-term care facility, you prioritize strict infection control prevention measures due to the understanding that the normal aging process weakens the body's defenses. Which theory of aging supports the necessity of strict infection control prevention measures?
Correct Answer: B
Rationale: The theory of aging that aligns with the need for strict infection control prevention measures is the Immunological Theory of Aging. This theory posits that aging leads to a decline in the body's immune defenses and a reduced ability of antibodies to protect against infections. The other theories do not directly address the impact of aging on the immune system. The Programmed Longevity Theory focuses on genetic changes affecting aging, the Endocrine Theory emphasizes hormonal changes, and the Rate of Living Theory relates longevity to the rate of oxygen metabolism.
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