NCLEX-RN
NCLEX RN Exam Review Answers
1. As a nursing supervisor in a long-term care facility, you prioritize strict infection control prevention measures due to the understanding that the normal aging process weakens the body's defenses. Which theory of aging supports the necessity of strict infection control prevention measures?
- A. The Programmed Longevity Theory
- B. The Immunological Theory of Aging
- C. The Endocrine Theory
- D. The Rate of Living Theory
Correct answer: B
Rationale: The theory of aging that aligns with the need for strict infection control prevention measures is the Immunological Theory of Aging. This theory posits that aging leads to a decline in the body's immune defenses and a reduced ability of antibodies to protect against infections. The other theories do not directly address the impact of aging on the immune system. The Programmed Longevity Theory focuses on genetic changes affecting aging, the Endocrine Theory emphasizes hormonal changes, and the Rate of Living Theory relates longevity to the rate of oxygen metabolism.
2. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?
- A. Electrical energy fields
- B. Spinal column manipulation
- C. Mind-body balance
- D. Exercise of joints
Correct answer: B
Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.
3. The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
- A. To tell the client this is not true; that we all have a purpose in life.
- B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
- C. To reassure the client that you know how the client is feeling and that things will get better.
- D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
4. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
- A. Collect and organize documents for the client's medical record
- B. Prepare the client's identification bracelet
- C. Identify pertinent health history data and current needs and limitations
- D. Gather the client's valuables and secure them in a locked container
Correct answer: C
Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.
5. Which of the following is an example of low health literacy skills?
- A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
- B. A client cannot read an admission form to sign it
- C. A nurse cannot calculate the correct IV rate for Ringer's lactate
- D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
Correct answer: B
Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.
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