NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What spinal change occurring with pregnancy alters mobility?
- A. Scoliosis.
- B. Kyphosis.
- C. Lordosis.
- D. Ankylosing spondylitis.
Correct answer: C
Rationale: The correct answer is 'Lordosis.' During pregnancy, the enlarging uterus places increased weight on the spine, causing an exaggerated inward curvature known as lordosis. This change alters mobility by shifting the center of gravity forward, leading to a compensatory change in posture. Scoliosis (choice A) is a sideways curvature of the spine, not typically associated with pregnancy. Kyphosis (choice B) is an exaggerated outward curvature of the spine, while ankylosing spondylitis (choice D) is a chronic inflammatory condition affecting the spine, neither of which are directly related to the spinal changes seen in pregnancy.
2. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
- A. Excess Fluid Volume
- B. Risk for Aspiration
- C. Disturbed Body Image
- D. Urinary Retention
Correct answer: C
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.
3. Which sign might a healthcare professional observe in a client with a high ammonia level?
- A. coma
- B. edema
- C. hypoxia
- D. polyuria
Correct answer: A
Rationale: A high ammonia level can lead to hepatic encephalopathy, which includes symptoms like confusion, disorientation, and can progress to coma. Coma is a severe condition of unconsciousness. Edema is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia is a condition of inadequate oxygen supply to tissues and organs, not directly related to high ammonia levels. Polyuria is excessive urination, which is not a typical sign of high ammonia levels.
4. An 85-year-old client is eligible for Medicare-reimbursable home care services. Referral is contingent on meeting which of the following criteria?
- A. homebound status, requiring skilled therapy care
- B. immediate previous hospitalization for acute care
- C. age
- D. requirement of nursing and social work support
Correct answer: A
Rationale: The correct criteria for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as physical therapy, occupational therapy, speech therapy, nursing, or social work. Choice A is correct because it aligns with these requirements. Choice B is incorrect as immediate previous hospitalization is not a prerequisite for home care services. Choice C is incorrect as age alone does not determine eligibility for Medicare-reimbursable home care services. Choice D is incorrect as the requirement of nursing and social work support alone is not sufficient for Medicare-reimbursable home care services.
5. What is the 24-hour day-night cycle known as?
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct answer: A
Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.
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