NCLEX-PN
2024 Nclex Questions
1. A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client’s tongue
- D. Checks the client’s ability to clench the teeth
Correct answer: Uses a tuning fork
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
2. When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?
- A. confront the staff member immediately and say, “You know that is not the treatment plan.”
- B. write an incident report to create a paper trail of the staff member’s failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct answer: ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
Rationale: When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.
3. A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct answer: C
Rationale: The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.
4. What is the profile of an individual who engages in domestic violence?
- A. from a minority culture in a low-income group.
- B. from a majority culture in a middle-income group.
- C. one who was never allowed to compete as a child.
- D. from any walk of life, race, income group, or profession.
Correct answer: from any walk of life, race, income group, or profession.
Rationale: Individuals who engage in domestic violence come from various backgrounds and cannot be stereotyped based on demographic factors like culture, income, or race. Research shows that perpetrators of domestic abuse can be found in any walk of life, regardless of their race, income group, or profession. It is important to note that the majority of domestic violence cases involve male perpetrators and female victims, but the profile of the abuser is not limited to specific demographic features. Therefore, the correct answer is that individuals who engage in domestic violence can come from any walk of life, race, income group, or profession. Choices A and B are incorrect as they wrongly associate domestic violence with specific cultural or income groups. Choice C is incorrect as there is no evidence to support the claim that being disallowed to compete as a child leads to domestic violence.
5. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client’s
- A. feelings about what has been described.
- B. thoughts about what has been described.
- C. possible solutions to the problem.
- D. intent in sharing the description.
Correct answer: thoughts about what has been described.
Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client’s thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.
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