NCLEX NCLEX-RN - National Council Licensure Examination(NCLEX-RN)
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,†the nurse might expect the client to describe which of the following?
A female client with major depression stated that “life is hopeless and not worth living.†The nurse should place highest priority on which of the following questions?
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4†and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
A 14-year-old boy fell off his bike while “popping a wheelie†on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Before giving methergine postpartum, the nurse should assess the client for:
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to “fatigue,†and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse’s assessment of her behavior would most likely be:
A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
