NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________lead(s) to his risk for falls.
- A. incontinence and loss of vision
- B. loss of vision
- C. incontinence
- D. loss of hearing
Correct answer: B
Rationale: Albert B. is at risk for falls due to two factors: his incontinence and his loss of vision. Loss of vision significantly impairs one's ability to navigate and avoid obstacles, thereby increasing the risk of falls. While incontinence is a risk factor for falls, the primary concern in this case is the loss of vision since it directly affects balance and safety. Therefore, the correct answer is 'loss of vision.' Choices A, C, and D are incorrect because they do not address the key factor of impaired vision leading to the risk of falls.
2. A client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client to sign an AMA order, the client refuses and leaves. What is the next action of the nurse?
- A. Call security to hold the client until he signs the order
- B. Notify the physician to convince the client to stay
- C. Speak with the client's spouse to persuade him to stay
- D. Allow the client to leave and document the refusal in his chart
Correct answer: D
Rationale: The nurse cannot force the client to stay in the hospital to receive treatment or to sign an AMA order. It is essential to respect the client's autonomy and decision-making capacity. While involving security or pressuring the client through the physician or spouse may seem like options, they are not appropriate in this situation. The nurse should allow the client to leave if they are competent to make that decision, document the refusal in the client's chart to ensure all actions are appropriately documented, and follow institutional policies for patients leaving against medical advice.
3. A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, 'You need to eat something while you are here. Food and proper nutrition are extremely important for your health.' What social philosophy is the nurse demonstrating?
- A. Ethnocentrism
- B. Relativism
- C. Stereotyping
- D. Xenocentrism
Correct answer: A
Rationale: The nurse's response reflects ethnocentrism, a belief that one's own cultural practices are superior to others. Ethnocentrism involves viewing one's own culture as the standard by which all others should be judged. In this scenario, the nurse's insistence that the client needs to eat disregards the client's cultural and spiritual beliefs, considering only the nurse's perspective as valid. B: Relativism is the recognition and acceptance of cultural differences without judgment. The nurse's behavior does not align with relativism as there is a lack of understanding and acceptance of the client's cultural practices. C: Stereotyping involves making assumptions about individuals based on predefined characteristics. While the nurse may have made assumptions, the core issue in this scenario is the belief in the superiority of one's own cultural practices. D: Xenocentrism is the opposite of ethnocentrism, where one perceives other cultures as superior to their own. The nurse's actions are not driven by a belief in the superiority of the client's culture but rather by a belief in the superiority of her own cultural practices.
4. All of the following are essential components of supervision EXCEPT:
- A. All tasks to be delegated or supervised are within the nurse's scope of practice
- B. The necessary tasks require repeated assessments
- C. The nurse has adequate time to develop staff assignments
- D. Policies have been developed that govern nursing practice
Correct answer: B
Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
5. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.
- A. Regular developmental screening is important to avoid secondary developmental delays.
- B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
- D. Parent support groups are helpful for sharing strategies and managing health care issues.
Correct answer: C
Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.
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