NCLEX RN Nursing Exam
Question 1 of 5.
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
A. Loss of ability to speak and communicate effectively
B. Aspiration and weight loss
C. Secondary infection resulting from poor oral hygiene
D. Drooling
Explanation: Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
Question 2 of 5.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
A. St. John's wort seldom relieves depression.
B. She should avoid eating aged cheese.
C. Skin reactions increase with the use of sunscreen.
D. The herbal is safe to use with other antidepressants.
Explanation: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
Question 3 of 5.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
A. Allow her to choose what foods she will eat
B. Provide activities to foster her self-identity
C. Encourage her to participate in morning exercise
D. Provide a private room near the nurse's station
Explanation: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.
Question 4 of 5.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
A. Zovirax (acyclovir)
B. Varivax (varicella vaccine)
C. VZIG (varicella-zoster immune globulin)
D. Periactin (cyproheptadine)
Explanation: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
Question 5 of 5.
The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
A. Preventing spasticity associated with cord injury
B. Decreasing the need for mechanical ventilation
C. Improving motor and sensory functioning
D. Treating post injury urinary tract infections
Explanation: High-dose methylprednisolone within 8 hours of spinal cord injury can improve motor and sensory outcomes by reducing inflammation and edema.
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