NCLEX-PN
Nclex 2024 Questions
1. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?
- A. "My sister still has episodes of crying, and it's been 3 months since Daddy died."?
- B. "Sally seems to have forgotten the bad things that Daddy did in his lifetime."?
- C. "She really had a hard time after Daddy's funeral. She said that she had a sense of longing."?
- D. "Sally has not been sad at all about Daddy's death. She acts like nothing has happened."?
Correct answer: D
Rationale: Abnormal grieving is often characterized by a lack of sadness or acknowledgment of the loss. In this scenario, the statement 'Sally has not been sad at all about Daddy's death. She acts like nothing has happened' indicates abnormal grieving as it suggests a lack of emotional response or denial of the death. On the other hand, choices A, B, and C all describe normal grieving reactions: crying episodes, selective memory of the deceased, and feelings of longing after the funeral. These responses are typical in the grieving process. Therefore, choice D is the correct answer, highlighting a potential abnormality in the grieving process.
2. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Administer eye drops immediately.
Correct answer: C
Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.
3. Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
- A. High-fiber
- B. Low-residue
- C. Bland
- D. Clear-liquid
Correct answer: D
Rationale: The correct answer is 'Clear-liquid.' After a hemorrhoidectomy, the client is usually started on a clear-liquid diet to allow the intestines to rest and promote healing. This diet helps prevent straining during bowel movements, which is crucial for recovery. Stool softeners are often included in the plan to avoid constipation. Once the client tolerates the clear liquids well, they can progress to a regular diet. High-fiber diet (choice A) is beneficial in the later stages of recovery to prevent constipation but is not typically the initial post-operative diet. Low-residue diet (choice B) and bland diet (choice C) are not appropriate for this type of surgery as they may not provide the necessary post-operative care and support needed for healing.
4. During the work phase of the nurse-client relationship, the client says to her primary nurse, "You think that I could walk if I wanted to, don't you?"? What is the best response by the nurse?
- A. "Yes, if you really wanted to, you could."?
- B. "Tell me why you're concerned about what I think."?
- C. "Do you think you could walk if you wanted to?"?
- D. "I think you're unable to walk now, whatever the cause."?
Correct answer: D
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client's self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client's anxiety by suggesting unresolved psychological conflicts related to walking.
5. The nurse is making initial rounds on a client with a C5 fracture and crutch field tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct answer: B
Rationale: A torque wrench is essential equipment to keep at the bedside for a client with a C5 fracture and crutch field tongs. This tool is used to tighten and loosen the screws of the crutch field tongs, allowing the nurse to adjust the pressure on the screws for proper support and alignment. A pair of forceps (choice A), wire cutters (choice C), and a screwdriver (choice D) are not required for managing crutch field tongs and, therefore, are incorrect choices in this scenario.
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