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. How can the dangers associated with wandering in Alzheimer's disease patients be prevented?
- A. Bed alarms
- B. Chair alarms
- C. Door alarms
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' Bed alarms, chair alarms, and door alarms are all effective measures to prevent the dangers associated with wandering in Alzheimer's disease patients. These alarms can alert caregivers when a patient tries to leave a designated area, helping to keep them safe. It is crucial to respond promptly to these alarms to ensure the patient's safety. Choices A, B, and C are incorrect individually as each type of alarm plays a vital role in a comprehensive wandering prevention strategy.
3. The client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?
- A. "I can lift weights and engage in resistance training."?
- B. "I should exercise until I am exhausted."?
- C. "I can incorporate aerobic exercises into my routine."?
- D. "I should perform proper stretching before starting my routine."?
Correct answer: B
Rationale: The correct answer is, "I should exercise until I am exhausted."? This statement indicates a need for further teaching because patients with multiple sclerosis should avoid exercising to the point of exhaustion or fatigue. Strenuous physical activity can increase body temperature and potentially worsen symptoms in individuals with multiple sclerosis. Choice A is correct because lifting weights and resistance training can be appropriate exercises for patients with multiple sclerosis. Choice C is valid because aerobic exercises can also be beneficial. Choice D is accurate as proper stretching before starting an exercise routine is essential for preventing injuries.
4. Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
5. What information should be collected when assessing the health status of a community?
- A. Air pollution levels
- B. Number of health food stores
- C. Most common causes of death
- D. Education level of the individuals
Correct answer: C
Rationale: When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.
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