NCLEX-RN
NCLEX RN Exam Preview Answers
1. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
- A. Asking questions may enhance the child's autonomy.
- B. Asking the child for permission helps develop a sense of trust.
- C. This question is an inappropriate statement because children at this age like to have choices.
- D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.
Correct answer: D
Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.
2. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
3. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
- B. Obtain a thorough history and physical assessment from the patient's family member.
- C. Immediately perform a complete history and physical assessment to obtain baseline information.
- D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Correct answer: D
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
4. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
- A. Performs the examination from both sides of the bed.
- B. Examines tender or painful areas last to help relieve the patient's anxiety.
- C. Follows a flexible examination sequence, considering the patient's age and condition.
- D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
5. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?
- A. Culture shock
- B. Cultural taboos
- C. Cultural unfamiliarity
- D. Culture disorientation
Correct answer: A
Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.
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