NCLEX RN Exam Review Answers

Extract:

Question 1 of 5

The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?

Correct Answer: B

Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills.
Choice A is incorrect as there is currently no cure for ASD.
Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility.
Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.

Question 2 of 5

A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?

A. Patients sleep better with the lights dimmed. B. The nightshift nurses prefer to work with less light. C. It's time for him to sleep, and you should, too. D. There's a reason we do that. Let me share a research study with you.

Correct Answer: D

Rationale: The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care.

Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.

Question 3 of 5

As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments. B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments. C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments. D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Correct Answer: D

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5.

Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

Question 4 of 5

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

A. Auditory hallucinations B. Bizarre behaviors C. Ideas of reference D. Motivation for activities

Correct Answer: D

Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice
A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice
B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice
C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.

Question 5 of 5

The client is receiving an MAOI. Which foods should the nurse caution the client to avoid?

A. Pork, spinach, and fresh oysters B. Milk, grapes, and meat tenderizers C. Cheese, beer, and products with chocolate D. Leafy green vegetables, fresh apples, and ice cream

Correct Answer: C

Rationale: The correct answer is C. When a client is receiving a monoamine oxidase inhibitor (MAOI), they should avoid foods high in tyramine to prevent a hypertensive crisis. Cheese, beer, and products with chocolate are rich in tyramine and can interact with MAOIs, leading to a dangerous rise in blood pressure.

Choices A, B, and D do not contain high levels of tyramine and are not typically restricted when taking MAOIs.

NCLEX RN Exam Review Answers - Nurselytic

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