NCLEX NCLEX-PN
NCLEX PN Practice Questions Quizlet
1. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct answer: getting a back rub and drinking a glass of warm milk
Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.
2. Under what circumstances is the legal right to confidentiality of client information waived?
- A. When a court system subpoenas information.
- B. When a family member requests health care information of a client.
- C. When a living will takes effect.
- D. When the client is declared incompetent by the legal system.
Correct answer: A
Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.
3. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct answer: developing interventions for grief and loss
Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.
4. A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?
- A. Polyphagia
- B. Polyuria
- C. Metabolic acidosis
- D. Lower extremity edema
Correct answer: Lower extremity edema
Rationale: Polyphagia, polyuria, and metabolic acidosis are common clinical signs of diabetes mellitus. Polyphagia refers to excessive hunger, polyuria is excessive urination, and metabolic acidosis can occur due to poorly controlled diabetes. Lower extremity edema, on the other hand, is not a typical clinical sign of diabetes mellitus. Edema in the lower extremities is more commonly associated with conditions like heart failure or kidney disease rather than diabetes mellitus.
5. A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
- A. Actual Chronic Low Self-Esteem (related to obesity).
- B. Potential Chronic Low Self-Esteem (related to obesity).
- C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
- D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
Correct answer: Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
Rationale: In this scenario, the client's recent weight loss and subsequent pregnancy could lead to concerns about weight regain and body image. The most appropriate nursing diagnosis is 'Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).' This diagnosis reflects the client's potential emotional response to the fear of losing the progress achieved through weight loss and dealing with changes in body image due to pregnancy. Options A and C imply that low self-esteem is already present, which is not supported by the information given. Option B is not as suitable as the client's self-esteem issues are more related to the fear of weight regain and pregnancy, making option D the best choice.
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