NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which body plane divides the body into right and left sides?
- A. Frontal Plane
- B. Medial Plane
- C. Median Plane
- D. Transverse Plane
Correct answer: C
Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.
2. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct answer: B
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.
3. A patient who is displaying the defense mechanism of Compensation would:
- A. Refuse to hear unwanted information.
- B. Transfer feelings of negativity to someone else.
- C. Overemphasize behaviors which accommodate for perceived weaknesses.
- D. Place blame on others for personal actions or mistakes.
Correct answer: C
Rationale: The correct answer is 'Overemphasize behaviors which accommodate for perceived weaknesses.' Compensation involves overemphasizing or exaggerating a particular behavior or trait to make up for or cover up perceived weaknesses in oneself. This defense mechanism allows individuals to focus on their strengths rather than acknowledging their shortcomings. Choices A, B, and D are incorrect. Refusing to hear unwanted information relates more to denial, transferring feelings of negativity to someone else is projection, and placing blame on others is an example of the defense mechanism known as externalization.
4. Which of the following is a fat-soluble vitamin?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin B-6
- D. Riboflavin
Correct answer: B
Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.
5. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
- A. Perform nursing activities throughout the entire shift
- B. Assess for signs of increased muscle tone
- C. Minimize environmental noise
- D. Teach clients to perform the Valsalva maneuver
Correct answer: C
Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
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