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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q371-Q376):
NEW QUESTION # 371
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
- A. Hallucination
- B. Illusion
- C. Delusion
- D. Conversion
Answer: D
Explanation:
Explanation
(A) The client's blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NEW QUESTION # 372
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
- A. Blood pressure increase from 100/80 to 115/85 after lunch
- B. Pulse rate ranges between 68 bpm and 76 bpm
- C. Temperature rise to 102°F rectally
- D. Headache that is unresponsive to acetaminophen (Tylenol)
Answer: C
Explanation:
Section: Questions Set F
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
NEW QUESTION # 373
As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:
- A. It may be a bid for attention and an indication that more diversionary activity should be planned for him
- B. No threat of suicide should be ignored or challenged in any way
- C. He needs to be observed carefully for signs that his depression has been relieved
- D. He needs to be confronted with his feelings and forced to work through them
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Threats of suicide should always be taken seriously. (B) This client has a life-threatening chronic illness. He may be concerned about dying or he may actually be contemplating suicide. (C) Sometimes clients who have made the decision to commit suicide appear to be less depressed. (D) Forcing him to look at his feelings may cause him to build a defense against the depression with behavioral or psychosomatic disturbances.
NEW QUESTION # 374
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
- A. Gavage tube
- B. Syringe
- C. A straw and cup
- D. Nipple and bottle
Answer: B
Explanation:
(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.
NEW QUESTION # 375
An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate?
- A. "You are in the hospital now. Calm down."
- B. "You once owned a restaurant. Tell me about it."
- C. "It is snowing outside. The restaurant is closed."
- D. "Go back to your room. You do not own a restaurant."
Answer: B
Explanation:
Explanation
(A) This response cuts off communication with the client. It does not address her feelings. (B) Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. (C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. (D) This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
NEW QUESTION # 376
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