NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.
Question 2 of 5
A nurse is teaching a 62-year-old female who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs:
Correct Answer: C
Rationale: Lymphedema can occur at any time after mastectomy with lymph node dissection due to disrupted lymphatic drainage, or it may never occur.
Question 3 of 5
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
Correct Answer: D
Rationale: Jaundice (
D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (
A) and ascites (
B) occur later. Anorexia (
C) is less specific.
Question 4 of 5
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of:
Correct Answer: B
Rationale: Left leg pain, positive Homans' sign (pain on dorsiflexion), and low-grade fever suggest deep vein thrombosis (DVT). Further assessment for swelling, redness, or warmth confirms this. Aortic aneurysm, I.V. drug abuse, and claudication present differently.
Question 5 of 5
The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every four hours while awake the client should use:
Correct Answer: C
Rationale: Mucositis in leukemia clients requires gentle oral care to prevent infection and promote healing. Saline or baking soda solution is soothing and non-irritating. Lemon-glycerin swabs can dry the mucosa, commercial mouthwash may irritate, and brushing may cause trauma.