NCLEX-PN
Physiological Adaptation NCLEX Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
Correct Answer: B
Rationale: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.
Question 2 of 5
A client with urinary tract calculi needs to avoid which of the following foods?
Correct Answer: B
Rationale: The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not.
Question 3 of 5
The highest incident of child abuse occurs in children in which age group?
Correct Answer: A
Rationale: Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). Girls are slightly more likely to be victims than boys.
Question 4 of 5
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
Correct Answer: B
Rationale: Urinary frequency is least indicative of UTI during pregnancy because it is a common minor discomfort of pregnancy and is caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are no problems. Frequency returns in the third trimester when the uterus drops into the pelvic cavity. A UTI has the symptoms of frequency, back pain, supra pubic discomfort, and malaise and is diagnosed by laboratory findings.
Question 5 of 5
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
Correct Answer: C
Rationale: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.