NCLEX NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
- A. Decreased HR
- B. Paresthesias
- C. Muscle weakness of the extremities
- D. Migraines
Correct answer: Migraines
Rationale: The correct answer is 'Migraines.' Migraines are not a symptom typically associated with hyperkalemia. In acute hyperkalemia, one would not expect to see migraines. Symptoms of hyperkalemia often include muscle weakness, paresthesias, and cardiac manifestations such as bradycardia or even cardiac arrest. Therefore, choices A, B, and C are more commonly associated with acute hyperkalemia compared to migraines, making it the correct choice.
2. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
- A. Psychological abuse
- B. Abandonment
- C. Material exploitation
- D. Physical abuse
Correct answer: A: Psychological abuse
Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.
3. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
- A. Review the chart for a signed consent for medication administration.
- B. Get the guardian's permission to give the medication.
- C. Do not give the medication and document the reason.
- D. Complete an incident report and notify the supervisor.
Correct answer: Do not give the medication and document the reason.
Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.
4. Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?
- A. Increasing heart rate above normal for the patient's age.
- B. Absent peripheral pulses
- C. Decreasing level of consciousness
- D. Increasing blood pressure
Correct answer: Increasing blood pressure
Rationale: In a patient in shock, increasing blood pressure is not a sign that compensatory mechanisms are failing. As shock progresses and compensatory mechanisms fail, systolic blood pressure will decrease, leading to hypotension, which is a late and ominous sign in these patients. Therefore, choices A, B, and C are warning signs of failing compensatory mechanisms in shock: an increasing heart rate above normal, absent peripheral pulses, and decreasing level of consciousness, respectively. An increasing blood pressure is not indicative of compensatory failure in shock; instead, it may be a sign of compensatory mechanisms still trying to maintain perfusion pressure.
5. Which of the following is a symptom associated with sensory overload?
- A. Disorientation
- B. Drowsiness
- C. Emotional lability
- D. Depression
Correct answer: Disorientation
Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.
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