NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future.
Choice B shows anger and isolation, not necessarily suicidal ideation.
Choice C demonstrates anger but no indication of suicidal thoughts.
Choice D shows anger towards the roommate, not self-harm intentions.
Question 2 of 5
Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?
Correct Answer: B
Rationale: The correct answer is B: Driving and staying safe. At 16, the teenager is likely preparing to start driving, so guidance on driving safety is crucial. An ankle fracture may impact their ability to drive safely. Other choices lack immediate relevance to the current situation. A: Puberty changes are important but may not be directly related to the hospitalization. C: Smoking hazards, while important, may not be a pressing concern during hospitalization. D: Social media influences, while relevant, are not as critical as driving safety in this scenario.
Question 3 of 5
A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
Correct Answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior involves verbal threats and emotional manipulation, causing fear and distress to the client. It violates the client's rights and dignity. Abandonment (
B) refers to deserting a client in need. Material exploitation (
C) involves misuse of a client's property or resources. Physical abuse (
D) involves causing harm through physical force.
Question 4 of 5
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number).
Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.
Question 5 of 5
Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?
Correct Answer: C
Rationale: The correct answer is C because using pantomime to explain a procedure to a deaf client is a cultural barrier. Deaf individuals may use sign language or have different communication preferences, so relying solely on pantomime may not effectively convey the necessary information. This can lead to misunderstandings or incomplete communication, impacting the quality of care provided.
Choice A is incorrect as offering materials at an 8th-grade reading level is a best practice in health literacy and not a cultural barrier.
Choice B may reflect cultural preferences but does not necessarily impede the provider's ability to provide care.
Choice D involves a client's spiritual beliefs but does not directly hinder the provider's ability to provide care.