NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?
- A. Inability to react appropriately to social cues
- B. Engages in repetitive behaviors
- C. Comprehends language well beyond the complexity expected for age
- D. Displays self-destructive behavior
Correct answer: C
Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.
2. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct answer: A
Rationale: The expected date of delivery is calculated using Nagle's rule which is: The first day of last menstrual period - 3 months + 7 days = the estimated date of delivery
3. A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:
- A. Set realistic limits to the client's behavior
- B. Repeat verbal instructions as often as needed
- C. Allow the client to express feelings to relieve tension
- D. Assign a staff member to be with the client at all times to help maintain control
Correct answer: A
Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.
4. A nurse with five years of experience working in a hospital unit is promoted as a mentor and preceptor to a new nursing staff. This is an example of:
- A. Collegiality
- B. Competence
- C. Advocacy
- D. Integration
Correct answer: A
Rationale: Collegiality is the action of forming relationships and supporting others through work experiences. In this scenario, the nurse being promoted as a mentor and preceptor exemplifies collegiality by fostering an encouraging educational relationship with the new nursing staff. The nurse demonstrates appropriate nursing care, teaches skills, and supports the professional growth of others. Choice B, 'Competence,' refers to having the necessary skills and knowledge, but in this context, the focus is on the supportive and educational role of the nurse. Choice C, 'Advocacy,' involves speaking up for patients' rights and needs, which is not directly demonstrated in the scenario. Choice D, 'Integration,' does not directly relate to the situation described, where the emphasis is on mentoring and guiding new staff.
5. A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?
- A. Encourage the client to participate in group therapy on the unit.
- B. Initiate one-to-one observation of the client.
- C. Focus the client on reality.
- D. Notify the provider of the client's statement.
Correct answer: B
Rationale: When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.
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