NCLEX-RN Certification Exam Questions with AI Explanations

QUESTION: 116

A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

The client is restless.
The elevated blood pressure causes photophobia.
Noise or bright lights may precipitate a convulsion.
External stimuli are annoying to the client with PIH.

Answer(s): C

Explanation:

(A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.

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QUESTION: 116

A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

The client is restless.
The elevated blood pressure causes photophobia.
Noise or bright lights may precipitate a convulsion.
External stimuli are annoying to the client with PIH.

Answer(s): C

Explanation:

(A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.

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QUESTION: 117

A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be:

"I wouldn't want to go home either; call a friend who could help you."
"Did you do something that could have made him so angry?"
"Let's talk about people and resources available to you so that you don't have to go home."
"I'll call the police and they will take care of him, and you can go home and get some rest."

Answer(s): C

Explanation:

(A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.

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QUESTION: 117

A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be:

"I wouldn't want to go home either; call a friend who could help you."
"Did you do something that could have made him so angry?"
"Let's talk about people and resources available to you so that you don't have to go home."
"I'll call the police and they will take care of him, and you can go home and get some rest."

Answer(s): C

Explanation:

(A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.

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QUESTION: 118

A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:

Assess for pain with plantiflexion
Assess for edema and heat of the right leg
Instruct him to rub the cramp out of his leg
Elevate right lower extremity with pillows propped under the knee

Answer(s): B

Explanation:

(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.

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QUESTION: 116

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QUESTION: 116

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QUESTION: 117

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QUESTION: 117

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QUESTION: 118

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