Free NCLEX PN and Rationale 2020 / 2021 122th Edition

Free NCLEX PN and Rationale 2020 / 2021 122th Edition

1. A nurse explains to a mother that her newborn is being admitted to the neonatal intensive care unit with a probable diagnosis of fetal alcohol syndrome (FAS) and explains this syndrome to the mother. The nurse determines that the mother understands this syndrome when the mother states:

A. “Withdrawal symptoms will occur after 3 days.”
B. “Mental retardation is unlikely to happen.”
C. “Withdrawal symptoms are tremors, crying, seizures, and reflexes that aren’t normal.”
D. “The reason the child is so large is because of the fetal alcohol syndrome.”

Answer: C. “Withdrawal symptoms are tremors, crying, seizures, and reflexes that aren’t normal.”

Rationale: The long-term prognosis for newborns with FAS is poor. Symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. Because of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or, at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely mentally retarded. The newborn is usually growth deficient at birth.

Test-Taking Strategy: Use the process of elimination and knowledge regarding FAS to answer this question. Options 2 and 4 can be eliminated first because of the word “unlikely” in option 2 and of the words “so large” in option D. From the remaining options, it is necessary to know that withdrawal symptoms can appear within 6 to 12 hours after life or, at the latest, within the first 3 days of life. Review the manifestations associated with FAS if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1074.

2. A female client is admitted to the inpatient mental health unit. When asked her name, she responds, “I am Elizabeth, the Queen of England.” The nurse recognizes this response as a(n):

A. Visual illusion
B. Auditory hallucination
C. Grandiose delusion
D. Loose association

Answer: C. Grandiose delusion

Rationale: A delusion is a personal belief that is almost certainly not true and resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. A hallucination is a false perception. Loose association is thinking characterized by speech in which ideas shift from one subject to another that are unrelated.

Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because the client is not having any visual or auditory disturbances. Option 4 is eliminated next because there is no indication of any examples of shifting of one subject to another. Making a reference to being a “royal” is a grandiose assumption. Review the characteristics of a grandiose delusion if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 112.

3. When a client has been raped, which action should a nurse take during the examination in the emergency room?

A. Try to avoid talking about what the client can expect to allay anxiety
B. Provide the person who accompanies the victim to the emergency room with a description of the procedures
C. Give the victim a concise description of the usual steps for a rape examination
D. Explain procedures to be completed and why these procedures are necessary

Answer: D. Explain procedures to be completed and why these procedures are necessary

Rationale: The individual who has been raped needs to trust the nurse in the emergency room. She or he must receive an explanation of the procedures and, also very importantly, why these are being completed. Option 2 does not address the client. Avoidance of talking and providing a concise description will not provide support and reassurance to the client.

Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first because it does not address the client. Eliminate option 1 next because the nurse would not avoid talking to the client. Eliminate option 3 because a “concise description” may increase anxiety. Review immediate care to the client who has been raped if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Mental Health
References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 274.
Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 811.

4. During admission data collection, a nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has an interference in the area of:

A. Muscle strength and flexibility
B. Balance and coordination
C. Sensation and reflexes
D. Bowel and bladder function

Answer: B. Balance and coordination

Rationale: The nurse is performing one test of cerebellar function, and in this case is checking for ataxia. Examples of disorders that include interferences in this area could be Parkinson’s disease, multiple sclerosis, or cerebrovascular accident. This test does not identify the problems addressed in options 1, 3, or 4.

Test-Taking Strategy: Use the process of elimination. Note that the question contains information about the leg tremors. Using nursing knowledge try to think of interferences that might contain that sign or symptom. Also note the relationship between “tremors” in the question and “coordination” in option B. Review data collection techniques for cerebellar function if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Musculoskeletal
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2030.

Read also:

• Free NCLEX PN 2020 / 2021 121th Edition
• Free NCLEX Practice Tests & Sample Questions 2020 / 2021 120th Edition
• NCLEX Questions and Answers pdf 119th Edition

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