NCLEX Practice Test and Answers with Rationale 90th Edition
NCLEX Practice Test and Answers with Rationale 90th Edition
1. A nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which of the following findings would be unassociated with spinal shock in this client?
A. Bowel sounds are absent.
B. The client’s abdomen is distended.
C. Respiratory excursion is diminished.
4. The blood pressure rises when the client sits up.
Answer: 4. The blood pressure rises when the client sits up.
Rationale: During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.
Test-Taking Strategy: Use the process of elimination and note the key word unassociated. This word indicates a false-response question and that you need to select the incorrect finding. Recalling that in spinal shock the blood pressure may fall when the client sits up will direct you to the correct option. Review these signs if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 650.
Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 439.
2. A nurse finds a client lying tense in bed and staring at the cardiac monitor. The client states, “There sure are a lot of wires around there. I sure hope we don’t get hit by lightning!” The appropriate nursing response would be:
A. “Would you like a mild sedative to help you relax?”
B. “Oh, don’t worry; the weather is supposed to be sunny and clear today!”
C. “Yes, all those wires must be a little scary. Did someone explain what the cardiac monitor was for?”
D. “Your family can stay tonight if they wish.”
Answer: C. “Yes, all those wires must be a little scary. Did someone explain what the cardiac monitor was for?”
Rationale: The nurse should initially respond to validate the client’s concern and then should determine the client’s knowledge level of the cardiac monitor. This gives the nurse an opportunity to perform client education if necessary. Bringing in the family, friends, or a chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Option 2 is a communication block.
Test-Taking Strategy: Use the process of elimination. Because the client is the first priority, the focus of the nurse’s concern should be the client’s feelings, preferences, and choices. Option 3 validates the client’s anxiety and goes a step further to determine why the client might be anxious. Remember, address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Adult Health/Cardiovascular
Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437.
3. A maternity nurse inspects the amniotic fluid from a client following an amniotomy. The nurse documents that the amniotic fluid is normal if which of the following is noted?
A. It is light green with no odor
B. It is thick and white with no odor
C. It is clear and dark amber
D. It is pale with flecks of vernix
Answer: D. It is pale with flecks of vernix
Rationale: Amniotic fluid is normally pale and straw-colored and may contain flecks of vernix caseosa. It should have a watery, not thick, consistency and no odor. Amber fluid suggests the presence of bilirubin, whereas greenish fluid may indicate the presence of meconium and suggests fetal distress.
Test-Taking Strategy: Focus on the issue—that the amniotic fluid is normal. Noting the words “flecks of vernix” in option 4 will direct you to this option. Review this content if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 108.
4. A mental health nurse is caring for a client with a diagnosis of mania. The nurse selects which appropriate activity for this client?
A. Letter writing
B. Walking
C. Participating in a paint-by-number activity
D. Listening to music
Answer: B. Walking
Rationale: A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will facilitate use of excess energy, yet not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities. Additionally, options 1 and 3 require concentration, a quality that is lacking in the manic state. Such activities may lead to increased frustration and anxiety for the client. Walking is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that this client is experiencing.
Test-Taking Strategy: Use the process of elimination, noting that options 1, 3, and 4 are similar in that they are relatively sedate activities. Review care to the client with mania if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 355.
Source : NCLEX Questions and answer
Like & Visit Our Facebook Fanspage at : https://www.facebook.com/NCLEX-Exam-for-Pass-103898044308313/
Thank you for your attention with reading our article NCLEX Practice Test and Answers with Rationale 90th Edition (Adult Health/Neurological/Cardiovascular/Maternity/Intrapartum/Mental Health). Thanks for your participation, like and share if this is usefull.
0 Response to "NCLEX Practice Test and Answers with Rationale 90th Edition"
Post a Comment