NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?
- A. Hurt, Insult, Threaten, and Scream (HITS)
- B. Humiliation, Afraid, Rape, and Kick (HARK)
- C. Slapped, Threatened, and Thrown (STaT)
- D. All of the above
Correct answer: D
Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.
2. The client has a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
- A. Isometric
- B. Range of motion
- C. Aerobic
- D. Isotonic
Correct answer: D
Rationale: The nurse should recommend isometric exercises for the muscles of the casted extremity. Isometric exercises involve contracting and relaxing muscles without moving the affected part. This type of exercise helps maintain muscle strength without moving the joint, which is important for clients with immobilized extremities. Range of motion exercises involve moving the joint through its full range of motion, which may not be suitable for a client with a long leg cast. Aerobic exercises focus on increasing cardiovascular endurance and may not be appropriate for a client with a casted extremity. Isotonic exercises involve muscle contractions with movement, which may not be safe for the affected extremity in a cast.
3. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
- A. A 26-year-old woman who had a bowel resection
- B. A 40-year-old man who underwent a hernia repair
- C. A 31-year-old woman with septicemia and who is on a ventilator
- D. A 91-year-old man with Alzheimer's disease recovering from a fall
Correct answer: A
Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.
4. A complication of osteoporosis is _______________?
- A. rheumatoid arthritis
- B. gouty arthritis
- C. dorsiflexion
- D. joint deformity
Correct answer: D
Rationale: Joint deformity is a well-known complication of osteoporosis, leading to structural changes in the joints due to bone loss and fragility. Gouty arthritis and rheumatoid arthritis are distinct types of arthritis that are not direct complications of osteoporosis. Dorsiflexion is a movement related to the foot's range of motion and is not a typical complication of osteoporosis.
5. A 3-year-old pediatric patient's mother would like to stay at the patient's bedside throughout the night as the patient seems calmer when she is present. What is the most caring and appropriate response?
- A. Reinforce visiting hours
- B. Allow her to stay for a short period beyond normal hours
- C. Allow her to stay throughout the night
- D. Offer to get bedding for a couch in the waiting room
Correct answer: C
Rationale: Allowing the mother to stay throughout the night is the most caring and appropriate response in this situation. Pediatric facilities often recognize the crucial role parents play in their child's care and are supportive of unlimited visitation. Allowing the mother to stay can help maintain the child's calmness and enhance the bond between the family and healthcare team. Reinforcing visiting hours (Choice A) may not address the specific needs of this situation where the child benefits from the mother's presence. Allowing her to stay for a short period beyond normal hours (Choice B) may not fully address the need for her continuous presence. Offering to get bedding for a couch in the waiting room (Choice D) may not be necessary if the mother can stay with her child in the patient's room.
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