NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?
- A. Decrease in body weight from his younger years
- B. Decrease in deposits of fat in the cheeks and forearms
- C. Presence of kyphosis and flexion in bilateral knees and hips
- D. Change in overall body proportion, including a longer trunk and shorter extremities
Correct answer: C
Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.
2. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
3. Which of the following is an anthropometric measurement?
- A. Blood pressure
- B. Temperature
- C. Pulse Rate
- D. Weight
Correct answer: D
Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.
4. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?
- A. Use an alcohol-based hand sanitizer to disinfect the hands
- B. Wash hands with soap and water using appropriate technique
- C. Notify the appropriate personnel about the exposure to client's blood
- D. Sample some of the client's blood to determine the presence of diseases
Correct answer: B
Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.
5. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
- A. Germ theory
- B. Naturalistic theory
- C. Magicoreligious theory
- D. Biomedical or scientific theory
Correct answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
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