NCLEX-PN
NCLEX Client Needs Physiologic Adaptation Questions
Extract:
Question 1 of 5
A nurse is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
Correct Answer: B
Rationale: Sagittal motion occurs in the midline plane of the body.
Question 2 of 5
A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
Correct Answer: C
Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning.
Question 3 of 5
Which of the following statements is correct regarding rape?
Correct Answer: B
Rationale: Spousal rape is legally recognized as non-consensual sexual intercourse within marriage. Most rapes are underreported, prosecution is challenging, and rapes occur in various locations, not predominantly at home.
Question 4 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 5 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.