NCLEX Questions Test Bank 2020 / 2021 114th Edition

NCLEX Questions Test Bank 2020 / 2021 114th Edition

1. A nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which of the following psychosocial issues?

A. Feelings of guilt are often associated with grief
B. The psychological needs of other children in the family and the ability to bear children in the future should be considered
C. Pain and discomfort occur as a result of the abortion
D. Grief and loss are usually resolved within 3 months

Answer: A. Feelings of guilt are often associated with grief

Rationale: Nurses must consider the psychological needs of the family experiencing spontaneous abortion. Grief often includes feelings of guilt. The grieving process is individual and may last a year or longer. It is not appropriate to focus on the client’s ability to have other children. The amount of pain and discomfort is important, but this is a physiological concern.

Test-Taking Strategy: The issue of the question relates to a psychosocial need. Use the process of elimination to eliminate option 3 because it describes a physiological concern. Option 2 is a nontherapeutic concern and can be eliminated. Knowledge related to the grieving process will direct you to option 1 from the remaining options. Review the psychosocial issues related to abortion if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 619-620.

2. A nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which of the following would the nurse check first?

A. Weight
B. Abdominal girth measurement
C. Pulse rate
D. Temperature

Answer: C. Pulse rate

Rationale: The primary concern when ectopic pregnancy is suspected is the occurrence of bleeding and hypovolemic shock. Option 3 is the only assessment that would provide information related to this occurrence. An elevated pulse rate is an indicator of shock. The nurse should also monitor for decreasing hematocrit levels and pain. Options 1, 2, and 4 do not provide data that would indicate the occurrence of hypovolemic shock.

Test-Taking Strategy: Note the key word first in the question. Knowledge regarding the complications associated with ectopic pregnancy will direct you to option C. Additionally, use the ABCs—airway, breathing, and circulation—to help direct you to the correct option. Review care to the client with a possible diagnosis of ectopic pregnancy if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 620-621.

3. A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client’s first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes?

A. “I shouldn’t have eaten so many sweets before I became pregnant.”
B. “Well, I guess I will just have to deal with this.”
C. “Oh, well, I guess this isn’t the end of the world.”
D. “I have heard that this type of diabetes is first discovered during pregnancy.”

Answer: A. “I shouldn’t have eaten so many sweets before I became pregnant.”

Rationale: Gestational diabetes is not necessarily caused by eating too many sweets before pregnancy. Options 2 and 3 indicate a common normal response. Option 4 is an accurate statement. Option 1 is the only option that indicates a knowledge deficit.

Test-Taking Strategy: Note the key words knowledge deficit in the question. Options 2 and 3 can be eliminated first because these are common client responses and are unrelated to a knowledge deficit. From the remaining options, recalling the causes of gestational diabetes will direct you to option A. Review gestational diabetes if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229.

4. A nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. The initial nursing action upon admission of the client is to:

A. Check the wound sites
B. Ask the client about the reason that the suicide act was attempted
C. Encourage and assist the client to vent feelings
D. Administer the prescribed antianxiety agent

Answer: A. Check the wound sites

Rationale: The physiological integrity of the client is always assessed first. Although options 2, 3, and 4 may be appropriate at some point, the initial action would be to assess the wounds.

Test-Taking Strategy: The key word in the question is initial. Use Maslow’s Hierarchy of Needs theory to prioritize. Physiological needs come first. Option 1 is the only option that addresses a physiological need. Review initial care to the client who attempted suicide if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 375.

Read also:

• NCLEX Questions Test Bank and Review 113th Edition
• NCLEX Questions Test Bank and Review 2019 / 2020 112th Edition
• Let's Learn NCLEX Questions with Answer 111th Edition

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