NCLEX-RN
NCLEX RN Exam Preview Answers
1. When planning a cultural assessment, what component should the nurse include?
- A. Family history
- B. Chief complaint
- C. Medical history
- D. Health practices
Correct answer: D
Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.
2. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?
- A. Germs and viruses
- B. Supernatural forces
- C. Eating imbalanced (hot/cold) foods
- D. Imbalance within his or her spiritual nature
Correct answer: B
Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.
3. Which of the following is part of client teaching regarding antiembolism stockings?
- A. Instruct the client to roll the top portion of the stocking down if it is too long
- B. Stockings are applied with the toes uncovered at the end
- C. Measure for thigh-high stockings from the foot to the knee
- D. Stockings are to be smooth from end to end without wrinkles
Correct answer: D
Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.
4. What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?
- A. Septum
- B. Sputum
- C. Separator
- D. None of the above
Correct answer: A
Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.
5. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.
- A. Hopelessness
- B. Power
- C. Interrupted sleep pattern
- D. Disturbed self-esteem
Correct answer: A
Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.
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