The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;

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Nursing Process NCLEX Questions Questions

Question 1 of 9

The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.

Question 2 of 9

Mr. Reyes has a possible skull fracture. The nurse should:

Correct Answer: A

Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size. Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures. Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture. Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.

Question 3 of 9

Which of the following terms indicates that the patient has a hearing loss caused by aging?

Correct Answer: B

Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.

Question 4 of 9

Which type of neuron transmits impulses from the central nervous system to the muscles and glands?

Correct Answer: C

Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion. Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.

Question 5 of 9

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?

Correct Answer: C

Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.

Question 6 of 9

The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?

Correct Answer: C

Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.

Question 7 of 9

Which of the ff conditions is evident by persistent hoarseness?

Correct Answer: C

Rationale: The correct answer is C: Laryngeal cancer. Persistent hoarseness is a common symptom of laryngeal cancer due to vocal cord involvement. Laryngeal cancer causes changes in voice quality over time. Bacterial infection (A) usually presents with acute symptoms and resolves with treatment. Aphonia (B) is the complete loss of voice, not persistent hoarseness. Peritonsillar abscess (D) causes sore throat and difficulty swallowing, but not persistent hoarseness.

Question 8 of 9

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Correct Answer: A

Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.

Question 9 of 9

Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?

Correct Answer: A

Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.

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