Practice NCLEX RN Questions
Question 1 of 5.
A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
A. Disturbed body image related to major changes in the structure and function of the larynx
B. Ineffective airway clearance related to excess mucus in airway, due to surgical procedure
C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
D. Impaired verbal communication related to inability to talk, due to removal of larynx
Explanation: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.
Question 2 of 5.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
C. Ignore the patient when she exhibits attention-seeking behavior.
D. Rotate the staff so the patient will learn to relate to more than one nurse.
Explanation: reward nonseeking attention behaviors by giving the patient unsolicited attention
Question 3 of 5.
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?
A. Limited adduction of the right leg.
B. Uneven gluteal fold and thigh creases.
C. Increase in length of the right limb.
D. Internal rotation of the right leg.
Explanation: folds and creases will be longer and deeper on affected side
Question 4 of 5.
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
A. Steadily increasing vital signs.
B. Mild tremors and irritability.
C. Decreased respirations and disorientation.
D. Stomach distress and inability to sleep.
Explanation: indication that the client is approaching delirium tremens, which can be avoided with additional sedation
Question 5 of 5.
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
A. I keep having recurring nightmares.
B. I have a headache and my vision is blurry.
C. I feel like I'm watching myself from outside my body.
D. I hear voices telling me what to do.
Explanation: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
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