NCLEX-RN
NCLEX RN Client Needs Physiologic Adaptation Questions
Extract:
Question 1 of 5
The nurse is caring for a client with suspected connective tissue disease. Assessment findings include chronic back pain, weight loss, joint pain and itching, and visual disturbances. The nurse anticipates a diagnosis of which disorder for this client?
Correct Answer: D
Rationale: Systemic necrotizing vasculitis (
D) causes back/joint pain, weight loss, itching, and visual issues due to vessel inflammation. Reiter (
A) involves arthritis/urethritis, Marfan (
B) affects connective tissue, and ankylosing spondylitis (
C) primarily causes spinal stiffness.
Question 2 of 5
The nurse is precepting a student nurse on leukemia classifications. Which statement by the student nurse reflects an understanding of classifications of leukemia?
Correct Answer: B
Rationale: Chronic myelogenous leukemia (CML) involves mostly granulocytes (
B) in the bone marrow. ALL onset is younger (
A), CML does not involve lymphocytes (
C), and AML includes various cells, not primarily granulocytes (
D).
Question 3 of 5
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
Correct Answer: D
Rationale: Cardiogenic shock causes hypotension, weak pulse, and cool, clammy skin (
D) due to poor perfusion. Hypertension (
A), warm skin (
B), and increased urine output (
C) are inconsistent with shock.
Question 4 of 5
A client presents to the emergency room with severe pain in the upper right abdomen. The client is nauseated and has a temperature of 102.2°F. Which nursing action would be a priority at this time?
Correct Answer: B
Rationale: Obtaining vital signs (
B) is the priority to assess stability in a client with suspected cholecystitis or appendicitis. Pain relief (
A), fluids (
C), and surgery (
D) follow assessment.
Question 5 of 5
The nurse is preparing to remove a client's abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?
Correct Answer: B
Rationale: Hand washing and gloves (
B) are sufficient for stitch removal, a clean procedure. Soap/water (
A) is unnecessary, sterile technique (
C) is excessive, and full PPE (
D) is not required.