NCLEX-PN
Nclex 2024 Questions
1. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
- A. Increasing the infant's fluid intake
- B. Maintaining the infant's body temperature at 98.6�F
- C. Minimizing tactile stimulation
- D. Decreasing caloric intake
Correct answer: A
Rationale: Bilirubin is excreted through the kidneys, therefore increasing fluid intake can help facilitate its elimination. Maintaining the infant's body temperature is important for overall health but does not directly assist in eliminating bilirubin, making choice B incorrect. Choices C and D are irrelevant to bilirubin elimination in this scenario and do not address the specific issue of physiologic jaundice.
2. The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this, the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct answer: B
Rationale: In the scenario provided, the nurse aims to reduce the client's use of denial and encourage the expression of feelings. Positive reinforcement for each expression of feelings is an effective approach to achieve this goal. By positively reinforcing the client's expression of feelings, the nurse encourages the desired behavior, making it more likely for the client to continue sharing their emotions. This approach creates a supportive and accepting environment for the client. In contrast, telling the client to stop using denial (Choice A) may create resistance and inhibit communication by putting pressure on the client. Instructing the client to express feelings (Choice C) is less effective as it lacks the element of reinforcement that is essential for behavior modification. Challenging the client each time denial is used (Choice D) may lead to defensiveness and hinder the therapeutic relationship, making it a less favorable option.
3. Which of the following statements is correct regarding rape?
- A. Most rapes go unreported.
- B. Legally, a woman can be raped by her spouse.
- C. Prosecuting and convicting for rape can be challenging.
- D. Rape can occur in different locations.
Correct answer: B
Rationale: The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses. Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system. Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming. Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.
4. When assessing a client with glaucoma, a nurse expects which of the following findings?
- A. Complaints of double vision
- B. Complaints of halos around lights
- C. Intraocular pressure of 15 mm Hg
- D. Soft globe on palpation
Correct answer: B
Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.
5. What are the three major sequential maturational crises for females?
- A. puberty, pregnancy, and menopause.
- B. death of a spouse, menopause, and childbirth.
- C. rape, divorce, and menarche.
- D. dating, engagement, and separation.
Correct answer: A
Rationale: The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. Puberty signifies the beginning of menarche, the first menstrual period. Pregnancy is a transformative experience with long-lasting effects on a woman's life. Menopause marks the end of menstrual cycles. These milestones are well-documented in research and are significant events in a woman's life. Nurses play a vital role in supporting females through these stages. Choices B, C, and D are incorrect as they do not accurately represent the recognized sequential maturational crises in a female's life.
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