NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. A patient is seen in the clinic for reports of “fainting episodes that started last week.” How would the nurse proceed with the examination?
- A. Blood pressure readings are taken in both arms and thighs.
- B. The patient is assisted to a lying position, and their blood pressure is taken.
- C. The patient’s blood pressure is recorded in lying, sitting, and standing positions.
- D. The patient’s blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.
Correct answer: The patient’s blood pressure is recorded in lying, sitting, and standing positions.
Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.
2. What does the term 'Afferent Nerve' mean?
- A. Carrying an impulse to the brain
- B. Carrying an impulse away from the brain
- C. Carrying impulses to the motor neurons of the appendicular muscles
- D. None of the above
Correct answer: Carrying an impulse to the brain
Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain. Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands. Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function. Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'
3. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct answer: A: Document that the client responds to the painful stimulus.
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
4. A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?
- A. CBC (Complete Blood Count)
- B. ECG (Electrocardiogram)
- C. Thyroid Function Tests
- D. CT Scan
Correct answer: CT Scan
Rationale: A CT scan is most likely to be performed in this scenario. A CT scan would be done to further investigate the cause of the left hemiparesis. Noncontrast CT scanning is commonly used in the acute evaluation of patients with suspected acute stroke to assess for ischemic changes or hemorrhage in the brain. While a CBC may provide information on blood cell counts and general health status, it is not the primary test for evaluating hemiparesis. An ECG is used to assess heart function and rhythm, which is not the main concern in this case. Thyroid function tests evaluate thyroid hormone levels and are not typically the initial tests for evaluating hemiparesis and confusion.
5. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct answer: Excessive physical activity
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.
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