NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?
- A. Early diagnosis and treatment provide the only means for a cure of ASD.
- B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
- C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
- D. Early diagnosis and treatment prevent your child from developing any other mental condition.
Correct answer: B
Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.
2. The client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?
- A. "I can lift weights and engage in resistance training."?
- B. "I should exercise until I am exhausted."?
- C. "I can incorporate aerobic exercises into my routine."?
- D. "I should perform proper stretching before starting my routine."?
Correct answer: B
Rationale: The correct answer is, "I should exercise until I am exhausted."? This statement indicates a need for further teaching because patients with multiple sclerosis should avoid exercising to the point of exhaustion or fatigue. Strenuous physical activity can increase body temperature and potentially worsen symptoms in individuals with multiple sclerosis. Choice A is correct because lifting weights and resistance training can be appropriate exercises for patients with multiple sclerosis. Choice C is valid because aerobic exercises can also be beneficial. Choice D is accurate as proper stretching before starting an exercise routine is essential for preventing injuries.
3. The client has a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
- A. Isometric
- B. Range of motion
- C. Aerobic
- D. Isotonic
Correct answer: D
Rationale: The nurse should recommend isometric exercises for the muscles of the casted extremity. Isometric exercises involve contracting and relaxing muscles without moving the affected part. This type of exercise helps maintain muscle strength without moving the joint, which is important for clients with immobilized extremities. Range of motion exercises involve moving the joint through its full range of motion, which may not be suitable for a client with a long leg cast. Aerobic exercises focus on increasing cardiovascular endurance and may not be appropriate for a client with a casted extremity. Isotonic exercises involve muscle contractions with movement, which may not be safe for the affected extremity in a cast.
4. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- A. Torticollis, with shortening of the sternocleidomastoid muscle
- B. Craniosynostosis, with premature closure of the cranial sutures
- C. Plagiocephaly, with flattening of one side of the head
- D. Hydrocephalus, with increased head size
Correct answer: A
Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.
5. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct answer: D
Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site
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