NCLEX-RN
NCLEX RN Exam Review Answers
1. A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?
- A. Allow the child to return to class and monitor for future events that are suggestive of abuse
- B. Call the parent and request an explanation for the bruises
- C. Call the police and ask for a warrant for the parent's arrest
- D. Notify the school administrator
Correct answer: D
Rationale: In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.
2. The client is receiving an MAOI. Which foods should the nurse caution the client to avoid?
- A. Pork, spinach, and fresh oysters
- B. Milk, grapes, and meat tenderizers
- C. Cheese, beer, and products with chocolate
- D. Leafy green vegetables, fresh apples, and ice cream
Correct answer: C
Rationale: The correct answer is C. When a client is receiving a monoamine oxidase inhibitor (MAOI), they should avoid foods high in tyramine to prevent a hypertensive crisis. Cheese, beer, and products with chocolate are rich in tyramine and can interact with MAOIs, leading to a dangerous rise in blood pressure. Choices A, B, and D do not contain high levels of tyramine and are not typically restricted when taking MAOIs.
3. Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:
- A. Auditory hallucinations
- B. Bizarre behaviors
- C. Ideas of reference
- D. Motivation for activities
Correct answer: D
Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.
4. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?
- A. Confront the delusional material directly by telling Gio that this simply is not so.
- B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
- C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
- D. Isolate Gio when he begins to talk about these beliefs.
Correct answer: B
Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.
5. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?
- A. Let them talk to another patient who has had the same therapy
- B. Provide research-based information about therapeutic hypothermia
- C. Connect them with the nurse manager
- D. Call the physician and ask him to talk to the family
Correct answer: B
Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.
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