NCLEX-RN Exam
Question 1 of 5.
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
A. Hypovolemic shock
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia
Explanation: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 2 of 5.
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
A. Hamburger
B. Hot dog
C. Potato salad
D. Baked beans
Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.
Question 3 of 5.
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
A. Ineffective family coping related to parental role conflict
B. Care-giver role strain related to chronic situational stress
C. Altered family process related to impaired social interaction
D. Altered parenting related to impaired growth and development
Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.
Question 4 of 5.
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines for himself
Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 5 of 5.
The nurse has just received the change of shift report. Which client should the nurse assess first?
A. A client with a supratentorial tumor awaiting surgery
B. A client admitted with a suspected subdural hematoma
C. A client recently diagnosed with akinetic seizures
D. A client transferring to the neuro rehabilitation unit
Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.
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