NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?
Correct Answer: C
Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.
Question 2 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.
Question 3 of 5
During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
Correct Answer: B
Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.
Question 4 of 5
Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
Correct Answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits.
Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
Question 5 of 5
An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?
Correct Answer: A
Rationale:
To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming.
Therefore, the correct answer is to appear unhurried and confident when examining the patient.
Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.