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PN Nclex Questions 2024
1. After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct answer: Victims of domestic violence are often the best predictors of their risk of harm.
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
2. All of the following are clinical manifestations indicating male climacteric except:
- A. hot flashes
- B. loss of reproductive ability
- C. headaches
- D. heart palpitations
Correct answer: loss of reproductive ability
Rationale: Male climacteric, also known as andropause, is a stage in a man's life characterized by a decline in testosterone levels and various physical and emotional changes. While men may experience symptoms like hot flashes, headaches, and heart palpitations during male climacteric, they do not typically lose their reproductive ability. Although fertility may decrease with age due to reduced testosterone production, men do not entirely lose the ability to reproduce. Therefore, the correct answer is 'loss of reproductive ability.' Choices A, C, and D are symptoms that can be associated with male climacteric, making them incorrect answers.
3. What is the appropriate intervention for a client who is restrained?
- A. Remove the restraints and provide skin care every hour.
- B. Document the condition of the client’s skin every 3 hours.
- C. Assess the restraint every 30 minutes
- D. Tie the restraint to the side rails.
Correct answer: Assess the restraint every 30 minutes
Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
4. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct answer: Hyperglycemic patient
Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.
5. An example of a process standard on a med-surg unit is:
- A. a procedure for changing IV tubing.
- B. a policy for staffing.
- C. the job description of the CEO (chief executive officer).
- D. a procedure for checking waveforms on a client being treated with an intra-aortic balloon pump.
Correct answer: a procedure for changing IV tubing.
Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting. Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit. Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff. Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.
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