NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 of 5
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
Correct Answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by an abrupt onset of pain. Symptoms of pleurisy include sudden sharp, stabbing pain that is usually unilateral and localized to a specific portion of the chest. The pain can be exacerbated by deep breathing. In contrast, pleural effusion is characterized by fluid accumulation in the pleural space, not sharp pain. Atelectasis involves collapse or closure of a lung leading to reduced gas exchange, but it does not typically present with sharp, stabbing pain. Tuberculosis is a bacterial infection that can affect the lungs but does not typically manifest with sudden sharp pain exacerbated by deep breathing.
Question 2 of 5
The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:
Correct Answer: A
Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice
B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice
C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice
D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.
Question 3 of 5
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
Correct Answer: A
Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed.
Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter.
Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.
Question 4 of 5
A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?
Correct Answer: A
Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation.
Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.
Question 5 of 5
Which of the following situations requires nurse intervention?
Correct Answer: C
Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public.
Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention.
Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.