NCLEX-RN
NCLEX RN Exam Review Answers
1. A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?
- A. Empathy
- B. Self-disclosure
- C. Disapproval
- D. False reassurance
Correct answer: B
Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.
2. A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
- A. A statement explaining the condition the client was found in, quoting the client's words about the situation
- B. An explanation of how the fall happened and when the physician was notified
- C. An account of the conditions of the room that contributed to the client's fall
- D. A summary of the client's medical history and current medications
Correct answer: A
Rationale: When a fall or injury occurs while under nursing care, it is crucial to document the known aspects of the situation and the response to the injury. In this scenario, the nurse should document the client's condition as found and quote the client's own words about the situation. This helps provide a clear account of the event without implying blame. Options B, C, and D are incorrect because detailing how the fall happened, listing room conditions, or summarizing medical history are not directly relevant to documenting the immediate situation and the client's own words following the fall.
3. Which of the following conditions may warrant a serum creatinine level?
- A. Rhabdomyolysis
- B. Digitalis toxicity
- C. Glomerulonephritis
- D. All answers are correct
Correct answer: D
Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
4. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
- A. The infant had doubled their birth weight at twelve months.
- B. The infant had tripled their birth weight at twelve months.
- C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
- D. The infant had grown ¼ inch since last month.
Correct answer: A
Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.
5. Which of the following statements is true regarding non-profit organizations?
- A. They are located in various areas, not specifically poor or rural ones.
- B. They are mandated to care for people, even if clients are unable to pay for services.
- C. The money they receive for services is reinvested back into their own business to further develop services.
- D. They are not referred to as proprietary organizations.
Correct answer: B
Rationale: Non-profit organizations are entities that operate for a social cause or public benefit, and they do not distribute profits to owners or shareholders. They are not limited to being located in poor or rural areas; they can be found in various locations. One key characteristic of non-profits is that they are obligated to provide services, regardless of a client's ability to pay. This ensures that essential services are accessible to all individuals in need. The statement 'The money they receive for services is reinvested back into their own business to further develop services' is correct. Non-profit organizations reinvest any surplus funds back into their operations to enhance the services they provide. The statement 'They are not referred to as proprietary organizations' is correct because proprietary organizations are typically for-profit entities, not non-profit ones.
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