NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 5
The clinic nurse is observing a student perform a complete physical assessment on a client. During the respiratory assessment, the clinic nurse determines that the student is using which physical assessment technique?
Correct Answer: C
Rationale:
To perform percussion, the nurse places the middle finger of the nondominant hand against the body's surface. The tip of the middle finger of the dominant hand strikes the top of the middle finger of the nondominant hand. Palpation is performed using the sense of touch. Inspection is the process of observation. Auscultation involves listening to the sounds produced by the body.
Question 2 of 5
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite.
Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary.
To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
Question 3 of 5
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
Correct Answer: C
Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.
Question 4 of 5
The nurse has been encouraging the intake of oral fluids for a client in labor to improve hydration. Which indicates a successful outcome of this action?
Correct Answer: B
Rationale: Urine specific gravity measures the concentration of the urine. During the first stage of labor, the renal system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine function. An elevated blood pressure and ketones in the urine are not expected outcomes related to labor and hydration. After the membranes have ruptured, it is expected that amniotic fluid may continue to leak.
Question 5 of 5
The nurse instructs a parent regarding the appropriate actions to take when the toddler has a temper tantrum. Which statement by the parent indicates a successful outcome of the teaching?
Correct Answer: A
Rationale: Ignoring a negative attention-seeking behavior is considered the best way to extinguish it, provided that the child is safe from injury. Option 2 is untrue and negative. Option 3 gives attention to the tantrum and also exceeds the recommended time of 1 minute per year of age for a time-out. Providing candy for rewards is unhealthy and unlikely to be effective at the end of the day.