NCLEX-PN
NCLEX Client Needs Physiologic Adaptation Questions
Extract:
Question 1 of 5
A nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.
Question 2 of 5
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
Question 3 of 5
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
Question 4 of 5
A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?
Correct Answer: B
Rationale: The initial tests to determine the basis for her symptoms (considering her fad dieting) should be a complete blood count, urinalysis, blood sugar, and other tests. The decision about further testing is then made based on these results, her history, and other factors.
Question 5 of 5
Which of the following describes the stages of domestic violence in an intimate relationship?
Correct Answer: B
Rationale: The cycle of abuse includes a honeymoon phase, stress escalation, an outburst (often violent), and reconciliation, increasing the risk of harm if unaddressed.