NCLEX-PN
Physiological Adaptation NCLEX PN Questions Questions
Extract:
Question 1 of 5
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.
Question 2 of 5
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
Correct Answer: B
Rationale:
Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety.
Choice 1 dismisses the client's feelings and offers false reassurance.
Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety.
Question 3 of 5
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
Correct Answer: D
Rationale: The incident report should always be filled out involving medication errors.
Question 4 of 5
The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
Correct Answer: A
Rationale: After physical needs of housing, clothing and food are met, the nurse should focus on assisting clients to manage the psychological effects of loss.
Question 5 of 5
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
Correct Answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. However, the nurse should ensure that the client is expressing herself authentically and is not trying to convince the nurse that there is no immediate danger. Further, proper authorities, such as the police, should be alerted to this reportable offense.