NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 of 5
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
Correct Answer: A
Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness.
Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections.
Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.
Question 2 of 5
A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:
Correct Answer: D
Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable.
Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement.
Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring.
Choice B suggests deferring the question to the physician, which is not the most supportive response.
Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.
Question 3 of 5
A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?
Correct Answer: A
Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation.
Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.
Question 4 of 5
A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?
Correct Answer: A
Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.
Question 5 of 5
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
Correct Answer: A
Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed.
Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter.
Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.