NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which of the following is one of the three smallest bones in the body?
- A. Vomer
- B. Distal phalanx of the small toe
- C. Stapes
- D. Coccyx
Correct answer: C
Rationale: The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.
2. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?
- A. The client most likely has a mental illness that should be treated before addressing sleep issues
- B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
- C. The client may become tired once they start talking
- D. None of the above
Correct answer: B
Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.
3. Which brain structure serves as the heat-regulating center?
- A. Hypothalamus
- B. Pituitary Gland
- C. Pons
- D. Medulla Oblongata
Correct answer: A
Rationale: The correct answer is the Hypothalamus. The hypothalamus is responsible for regulating body temperature, ensuring it stays within a narrow range. Moreover, the hypothalamus controls various essential bodily functions, such as hunger, thirst, and circadian rhythms. Choices B, C, and D are incorrect because the Pituitary Gland primarily produces and releases hormones, the Pons is involved in functions like sleep, respiration, and bladder control, and the Medulla Oblongata controls vital functions like breathing and heart rate, but not body temperature regulation.
4. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?
- A. Acromegaly
- B. Marfan syndrome
- C. Hypopituitary dwarfism
- D. Achondroplastic dwarfism
Correct answer: C
Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.
5. Patients who cannot move in their bed on their own should be turned at least ________________.
- A. once a day
- B. twice a day
- C. every 2 hours
- D. every 4 hours
Correct answer: C
Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.
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