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NCLEX RN Exam Preview Answers
1. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct answer: May also be seeking the assistance of a shaman or medicine man.
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
2. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
- A. Referred pain
- B. Superficial pain
- C. Radiating pain
- D. Precipitating pain
Correct answer: Radiating pain
Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.
3. A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient?
- A. Deep breathing techniques to increase oxygen levels.
- B. Cough regularly and deeply to clear airway passages.
- C. Cough following bronchodilator utilization.
- D. Decrease CO2 levels by increasing oxygen intake during meals.
Correct answer: Cough following bronchodilator utilization.
Rationale: The correct answer is to instruct the patient to cough following bronchodilator utilization. In COPD and PVD patients, bronchodilators help to open up the airways, making coughing more effective in clearing secretions from the lungs. This instruction can aid in improving the patient's ability to breathe by enhancing airway clearance. Deep breathing techniques (Choice A) may help increase oxygen levels but may not directly address the patient's immediate concern of breathing difficulty. Coughing regularly and deeply (Choice B) can be beneficial, but the timing following bronchodilator use is more crucial to maximize its effectiveness. Decreasing CO2 levels by increasing oxygen intake during meals (Choice D) does not directly address the patient's concern about breathing ease or the role of bronchodilators in improving cough effectiveness.
4. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?
- A. Possible fracture of the tibia.
- B. Bruising of the gastrocnemius muscle.
- C. Possible fracture of the radius.
- D. No anatomic injury, the child wants his mother to carry him.
Correct answer: Possible fracture of the tibia.
Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb. Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk. Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk. Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.
5. Plantar flexion can be prevented with ________________.
- A. foot soaks
- B. foot boards
- C. toenail care
- D. proper shoes
Correct answer: foot boards
Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.
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