victor is a 43 year old patient who is hiv positive with a diagnosis of pneumocystis carinii pneumonia pcp who has been admitted to the hospital his p

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. Victor, a 43-year-old patient who is HIV positive with a diagnosis of pneumocystis carinii pneumonia (PCP), has been admitted to the hospital. His prognosis is very poor, and his partner, Roger, would like to have a ceremony performed in his room to honor their union in case something happens to Victor, who agrees. What is the most appropriate response to their request?

A. Inform them that Victor is too ill for a ceremony
B. Ask the social worker to intervene
C. Tell them it's against hospital policy
D. Coordinate with other disciplines to support their request

Correct answer: D

Rationale: The most appropriate and compassionate response is to respect Victor and Roger's relationship and honor their wishes. Coordinating with other disciplines, such as social work, chaplaincy, or patient advocacy, to support their request demonstrates a holistic approach to care. This collaborative effort can facilitate the ceremony and provide emotional support to both Victor and Roger during a challenging time. Upholding their request aligns with the principles of patient-centered care and promotes dignity and respect, as outlined in the ANA Code of Ethics. Informing them that Victor is too ill for a ceremony (Choice A) would dismiss their emotional needs and fail to address their request. Involving the social worker without understanding the specific request (Choice B) may not directly address their desire for a ceremony. Telling them it's against hospital policy (Choice C) disregards the importance of honoring patient preferences and may cause unnecessary distress in an already sensitive situation.

2. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?

A. The client is an emancipated minor
B. The mother has to work and is unavailable
C. The client has a job and a driver's license
D. The mother does not speak English

Correct answer: A

Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.

3. The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?

A. Inability to react appropriately to social cues
B. Engages in repetitive behaviors
C. Comprehends language well beyond the complexity expected for age
D. Displays self-destructive behavior

Correct answer: C

Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.

4. 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

5. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?

A. Hyponatremia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypercalcemia

Correct answer: D

Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.