NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct answer: B
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.
2. Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: C
Rationale: Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.
3. The most accurate reading for a temperature is done:
- A. Orally
- B. Aurally through a clean canal
- C. Rectally
- D. Axially
Correct answer: B
Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.
4. Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
5. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
- A. Help the client to get settled and conduct the interview the next morning when the client is rested
- B. Conduct the interview immediately, directing the majority of the questions to the client
- C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
- D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication
Correct answer: C
Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.
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