NCLEX-PN
Nclex Practice Questions 2024
1. A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. a panic attack.
Correct answer: C
Rationale: The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.
2. A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
- A. "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."?
- B. "Often women become offended if asked about their safety in relationships."?
- C. "It is mandatory that all women be questioned about domestic violence."?
- D. "How would you feel to know that her partner is beating her and you didn't ask?"?
Correct answer: A
Rationale: The correct answer is, "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."? There is a well-documented correlation between vague symptoms like abdominal pain and battered woman syndrome. It is crucial for healthcare providers to inquire about potential domestic violence when presented with such symptoms. Choice B is incorrect as studies show that women are not generally offended by appropriately phrased questions about their safety in relationships. While it is not mandatory to question all women about domestic violence, it is advisable to at least ask a screening question regarding safety. Choice D is inappropriate as it uses a shaming tactic, which is not constructive and may create a hostile work environment. It's important for healthcare professionals to approach sensitive topics like domestic violence with empathy and professionalism.
3. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
- A. "I live by myself."?
- B. "I have trouble seeing."?
- C. "I have a cat in the house with me."?
- D. "I usually drive myself to the doctor."?
Correct answer: B
Rationale: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and are incorrect. Living alone (Choice A) does not necessarily indicate a need for follow-up unless there are specific concerns. Having a cat at home (Choice C) and driving to the doctor (Choice D) are not direct indicators of the client's ability to care for himself.
4. What is the first exercise that should be performed by a client who had a mastectomy?
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct answer: D
Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.
5. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about the possibility of sexual abuse.
- B. ask about the types of foods the child is eating.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct answer: A
Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.
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