NCLEX NCLEX-PN
2024 Nclex Questions
1. The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
- A. reactive.
- B. maturational.
- C. situational.
- D. adventitious.
Correct answer: situational.
Rationale: The mother is experiencing a situational crisis as the unexpected birth of a child with a cleft lip and palate has placed her in a challenging situation she did not anticipate. This type of crisis is triggered by specific events and circumstances. Choice A, reactive, implies responding to a stressor after it has occurred, which is not the case here. Choice B, maturational, refers to stress related to developmental stages, not to external events like the child's condition. Choice D, adventitious, involves crises resulting from events outside one's control, such as natural disasters, which do not apply in this scenario.
2. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
- A. Facial flushing
- B. A complaint of chest heaviness
- C. Heart rate increase of 10 beats/min
- D. Systolic blood pressure increase of 10 mm Hg
Correct answer: B: A complaint of chest heaviness
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
3. A mother has just given birth to a baby who died soon after. The mother has been crying and states, “I can’t believe this has happened to me. I did everything right during this pregnancy.” How should the nurse respond to this mother?
- A. Tell her she did nothing wrong; it was God’s will.
- B. Tell her she can have another baby.
- C. Tell her that her behavior is not going to solve anything.
- D. Tell her nothing and let her mourn this loss in the manner she chooses.
Correct answer: Tell her nothing and let her mourn this loss in the manner she chooses.
Rationale: Perinatal loss is a significant tragedy for parents, and it is crucial to provide sensitive and compassionate care. When a mother expresses her disbelief and feelings of doing everything right during the pregnancy, it is important for the nurse to acknowledge her pain and allow her to grieve in her way. Telling her that she did nothing wrong and it was God's will (Choice A) may not be comforting and can come across as dismissive of her feelings. Suggesting she can have another baby (Choice B) is insensitive and overlooks the grief she is experiencing for the current loss. Telling her that her behavior is not going to solve anything (Choice C) is invalidating her emotions and not supportive in this situation. Therefore, the best approach is to support her in her mourning process by respecting her feelings and allowing her to express her grief as she sees fit.
4. A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct answer: C
Rationale: The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.
5. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?
- A. Collect health history information first while initiating emergency measures.
- B. Ask health history questions while performing the examination and initiating emergency measures.
- C. Collect all information requested on the history form, including social support, strengths, and coping patterns.
- D. Perform emergency measures and delay health history questions until after treating the fractures in the operating room.
Correct answer: B
Rationale: When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99