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NCLEX RN Exam Review Answers
1. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?
- A. ''All elderly individuals experience depression occasionally.''
- B. ''I'm relieved that I will improve within 2 or 3 days.''
- C. ''I never realized depression could occur without a specific cause.''
- D. ''Reducing stress in my life will alleviate the depression.''
Correct answer: ''I never realized depression could occur without a specific cause.''
Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.
2. Where is the Loop of Henle located in the body?
- A. Liver
- B. Kidney
- C. Heart
- D. Ear
Correct answer: Kidney
Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.
3. Which technological advance is MOST likely to place you at risk for HIPAA violations?
- A. Social media
- B. Word processing programs
- C. Spreadsheets
- D. Cloud storage services (Clouds and SOEs)
Correct answer: Social media
Rationale: The correct answer is Social media. Social media platforms such as Facebook can significantly put you at risk for HIPAA violations. It is crucial to never share any patient-related information or comments on social media websites, as this breaches patient confidentiality and violates HIPAA regulations. Choices B, C, and D are less likely to directly lead to HIPAA violations. Word processing programs and spreadsheets are commonly used for documentation and data organization, focusing more on internal operations and not on external sharing of sensitive information that can compromise patient confidentiality. Cloud storage services (Clouds and SOEs) are designed for secure data storage and sharing within regulated environments, and HIPAA compliance can be maintained if used appropriately. However, social media's open and unsecured nature makes it a higher risk for HIPAA violations compared to the other technological advances mentioned.
4. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
- A. The child is asked to undress from the waist up.
- B. The head is examined before the thorax, abdomen, and genitalia.
- C. The nurse should keep in mind that a child at this age will have a sense of modesty.
- D. Talking about the equipment being used is avoided to prevent increasing the child’s anxiety.
Correct answer: The nurse should keep in mind that a child at this age will have a sense of modesty.
Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.
5. When preparing to perform a physical examination on an infant, what should the nurse do?
- A. Have the parent remove all clothing except the diaper.
- B. Instruct the parent not to feed the infant immediately before the examination.
- C. Allow the infant to suck on a pacifier during abdominal auscultation.
- D. Ensure the parent is present during the examination.
Correct answer: Have the parent remove all clothing except the diaper.
Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.
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