NCLEX-RN
Evaluation Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.
Question 3 of 5
The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.
Question 4 of 5
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
Question 5 of 5
The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.