NCLEX-RN
NCLEX RN Exam Prep
1. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?
- A. The client most likely has a mental illness that should be treated before addressing sleep issues
- B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
- C. The client may become tired once they start talking
- D. None of the above
Correct answer: B
Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.
2. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?
- A. Acromegaly
- B. Marfan syndrome
- C. Hypopituitary dwarfism
- D. Achondroplastic dwarfism
Correct answer: C
Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.
3. Which of the following is an example of client handling equipment?
- A. Wheelchair
- B. Height-adjustable bed
- C. Shower chair
- D. Call light
Correct answer: B
Rationale: Client handling equipment is designed to reduce stress and workload on healthcare professionals who assist, turn, or lift clients, aiming to decrease the risk of injuries from improper lifting techniques. A height-adjustable bed is a prime example of client handling equipment as it allows healthcare providers to raise the client to a suitable working height, facilitating care provision. Choices A, C, and D are not examples of client handling equipment. While a wheelchair, shower chair, and call light are essential in client care settings, they are not intended to aid in handling and lifting clients.
4. The client reports nausea and constipation. Which of the following would be the priority nursing action?
- A. Collect a stool sample
- B. Complete an abdominal assessment
- C. Administer an anti-nausea medication
- D. Notify the physician
Correct answer: B
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.
5. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?
- A. Red rash across the trunk and extremities
- B. Nausea, vomiting, seizures
- C. Flushing of the face and neck
- D. Abdominal pain radiating to the back
Correct answer: B
Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.
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