NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
Correct Answer: D
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty.
Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
Question 2 of 5
A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?
Correct Answer: A
Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.
Question 3 of 5
After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?
Correct Answer: D
Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive.
Choice A is incorrect as health care providers are recognizing the value of self-treatment.
Choice B is incorrect because self-treatment can be effective in many cases.
Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.
Question 4 of 5
While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
Correct Answer: A
Rationale: When percussing over relatively dense organs, such as the liver or spleen, a dull sound is a normal finding due to the organ's density. This occurs because the sound waves produced by tapping on the organ travel through the dense tissue, resulting in a dull sound.
Therefore, the correct action for the nurse in this scenario is to consider a dull sound over the liver as a normal finding. Palpating for an underlying mass (
Choice
B) is not indicated based on the percussion finding alone. Repositioning the hands and repeating the percussion (
Choice
C) may not change the dull sound over the liver. Referring the patient for additional treatment (
Choice
D) without understanding the normal percussion findings over the liver would be premature. Thus, the most appropriate action is to interpret the dull sound as a normal finding.
Question 5 of 5
When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
Correct Answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress.
Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.