which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

A. "I can always trust my family."?
B. "It seems like I always have bad luck."?
C. "You never know who will turn against you."?
D. "I hear evil voices that tell me to do bad things."?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

2. The Rule of Nines is used to:

A. determine the amount of the body surface that has been burned
B. assess the level of oxygen saturation in a body that has been burned.
C. determine the level of tissue damage that has occurred in a burn.
D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

3. What are Korotkoff sounds?

A. Sounds noted during diastole.
B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
C. Sounds only noted by skilled cardiologists.
D. Distinct sounds which are classified into 6 phases.

Correct answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

4. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?

A. Wake the infant before beginning the examination.
B. Examine the infant's hips before the infant wakes up.
C. Auscultate the lungs and heart while the infant is still sleeping.
D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.

Correct answer: C

Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.

5. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?

A. Chronic diseases such as hypertension do not usually cause weight loss.
B. Weight loss is more likely due to underlying medical conditions than unhealthy eating habits.
C. Unexplained weight loss often accompanies short-term illnesses.
D. Weight loss is not typically caused by mental health dysfunctions.

Correct answer: C

Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.