NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
Which response would best assist the chemically impaired client in dealing with issues of guilt?
Correct Answer: B
Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively.
Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions.
Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive.
Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.
Question 2 of 5
The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?
Correct Answer: C
Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.
Question 3 of 5
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
Correct Answer: C
Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.
Question 4 of 5
A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
Correct Answer: A
Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice
B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice
C) is not the most probable cause given the history provided. Metabolic alkalosis (choice
D) is not associated with sudden seizing in this context.
Question 5 of 5
Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
Correct Answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect.
Therefore, the other options are appropriate for the care of a child with hepatitis.