NCLEX-PN
Best NCLEX Next Gen Prep
1. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct answer: C
Rationale: All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.
2. A client with dumping syndrome should..........................while a client with GERD should..........................
- A. Sit up 1 hour after meals; lie flat 30 minutes after meals
- B. Lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. Sit up after meals; sit up after meals
- D. Lie down after meals; lie down after meals
Correct answer: D
Rationale: For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.
3. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?
- A. McGill Pain Scale
- B. FLACC Pain Scale
- C. CRIES Pain Scale
- D. Wong-Baker Pain Scale
Correct answer: D
Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.
4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?
- A. Dull sounds
- B. Hyperresonance sounds
- C. Hypoactive bowel sounds
- D. An absence of bowel sounds
Correct answer: A
Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.
5. Which of the following vaccines contains a live virus?
- A. varicella
- B. IPV
- C. DTaP
- D. hepatitis B
Correct answer: A
Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.
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