NCLEX-RN
NCLEX RN Exam Questions Questions
Question 1 of 5
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
Correct Answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life. Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
Question 2 of 5
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
Correct Answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life. Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
Question 3 of 5
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent's remark: "We just don't know how he caught the disease!"? The nurse's response is based on an understanding that:
Correct Answer: D
Rationale: The correct answer is that acute glomerulonephritis (AGN) is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease triggered by an antecedent streptococcal infection occurring 4 to 6 weeks prior. It is considered a noninfectious renal disease. Choice A is incorrect because AGN is not a streptococcal infection that involves the kidney tubules but rather a noninfectious renal disease. Choice B is incorrect as AGN is not easily transmissible in schools and camps but is a result of a previous streptococcal infection. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections, but with a previous streptococcal infection.
Question 4 of 5
Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?
Correct Answer: B
Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.
Question 5 of 5
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
Correct Answer: B
Rationale: In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.
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