NCLEX NCLEX-RN
NCLEX RN Exam Prep
1. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?
- A. Is something wrong with the bath water?
- B. Just calm down, we'll finish your bath soon.
- C. Are you trying to tell me something?
- D. Shall I turn on the television?
Correct answer: Is something wrong with the bath water?
Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.
2. A client injured in a motor vehicle accident was brought to the emergency department and taken immediately for a scan. The client’s family arrives and asks about the client’s condition. Which response would the nurse provide?
- A. Please do not worry; everything will be all right.
- B. I am sorry; I do not have any information about the client.
- C. You will have to wait for the primary health care provider.
- D. Please wait; I will update you as soon as I have any information.
Correct answer: Please wait; I will update you as soon as I have any information.
Rationale: In this situation, the most appropriate response for the nurse to provide to the client's family is to assure them that they will be updated as soon as there is relevant information available. This response not only acknowledges the family's concern but also demonstrates the nurse's commitment to keeping them informed. Option A, providing false reassurances, is not advisable as it may impact the family's ability to cope with potential bad news. Option B, stating that the nurse has no information, is not helpful and can cause distress. Option C, directing the family to the primary health care provider, is not ideal as the nurse should strive to communicate directly with the family to establish trust and provide support.
3. A patient scheduled for cataract surgery asks the nurse why they developed cataracts and how to prevent it in the future. What is the nurse's best response?
- A. Age is the biggest factor contributing to cataracts.
- B. Unprotected exposure to UV lights can cause cataracts.
- C. Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
- D. Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.
Correct answer: Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
Rationale: The correct answer is C: 'Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.' This response is the best choice as it covers the most common contributing factors for cataracts and includes preventable risk factors. Choice A is incorrect because while age is a significant factor in cataract development, it is not the only one. Choice B is incorrect as UV light exposure is a risk factor for cataracts but not the most comprehensive response. Choice D is incorrect as there are preventive measures individuals can take to reduce their risk of developing cataracts, such as protecting their eyes from UV light and managing other risk factors.
4. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?
- A. Skin has a purple/bluish color
- B. Capillary refill is 1 second
- C. Skin appears blanched at the pressure site
- D. Tenting appears when checking skin turgor
Correct answer: Skin has a purple/bluish color
Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.
5. A patient diagnosed with alopecia would be described as having:
- A. body lice
- B. lack of ear lobes
- C. Indigestion
- D. hair loss
Correct answer: hair loss
Rationale: The correct answer is 'hair loss.' Alopecia is a medical term that specifically refers to the condition of hair loss, usually in patches or all over the body. Choice A, 'body lice,' refers to a parasitic infestation and is not related to alopecia. Choice B, 'lack of ear lobes,' is completely unrelated to the term alopecia, which is solely about hair loss. Choice C, 'Indigestion,' has no connection to alopecia as it pertains to digestive issues, not hair loss. Therefore, the correct description for a patient diagnosed with alopecia is 'hair loss.'
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