NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.
Question 2 of 5
A 56-year-old cancer survivor feels guilty at the 'I Can Cope' meetings. The nurse can help him manage his feelings of guilt by pointing out that:
Correct Answer: D
Rationale: Survivor guilt is a normal reaction for cancer survivors, especially in support groups, and acknowledging this helps the client process their emotions.
Question 3 of 5
When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:
Correct Answer: D
Rationale: Low thyroid hormone levels in hypothyroidism can cause depression and sadness, which typically improve with thyroid hormone replacement therapy.
Question 4 of 5
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. The nurse should first:
Correct Answer: B
Rationale: In an acute asthma attack with severe dyspnea, initiating oxygen therapy corrects hypoxemia, a priority. Bronchodilators are critical but secondary to oxygenation. I.V. fluids and breathing techniques are supportive but not immediate priorities.
Question 5 of 5
After the administration of t-PA, the assessment priority is to:
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.