Comprehensive NCLEX-RN| Quiz #2: 75 Questions and
Correct Answers/ Rationale (2022 update)
65. Question
Category: Psychosocial Integrity
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most
likely affect the behavior?
A. Strange bed and surroundings.
B. Separation from parents.
C. Presence of other toddlers.
D. Unfamiliar toys and games.
Correct Answer: B. Separation from parents
Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed
on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to
withstand other stress.
66. Question
Category: Psychosocial Integrity
While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive
development at this age?
A. They are able to make simple associations of ideas.
B. They are able to think logically in organizing facts.
C. Interpretation of events originates from their own perspective.
D. Conclusions are based on previous experiences.
Correct Answer: B. They are able to think logically in organizing facts.
The child in the concrete operational stage, according to Piaget, is capable of mature thought when
allowed to manipulate and organize objects.
67. Question
,Category: Psychosocial Integrity
The nurse has just admitted a client with severe depression. From which focus should the nurse identify
a priority nursing diagnosis?
A. Nutrition
B. Elimination
C. Activity
D. Safety
Correct Answer: D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the
plan. Depression can be effectively treated in primary care setti ngs using an evidence-based
collaborative approach in which primary care providers are systematically supported by mental health
providers in caring for a caseload of patients.
68. Question
Category: Safety and Infection Control
Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized
children?
A. Sports and games with rules
B. Finger paints and water play.
C. “Dress-up” clothes and props.
D. Chess and television programs
Correct Answer: A. Sports and games with rules
The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical reasoning and
social skills are developed through play.
69. Question
Category: Health Promotion and Maintenance
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family
suggests they encourage the client to rest frequently in which of the following positions?
A. High Fowler’s
,B. Supine
C. Left lateral
D. Low Fowler’s
Correct Answer: A. High Fowler’s
Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac workload and
facilitates breathing.
70. Question
Category: Physiological Adaptation
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will
indicate that the child has adequate fluid replacement is:
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn
Correct Answer: A. Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium -
ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and
cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These
mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary
permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic
solutes, and plasma proteins between the intravascular and interstitial spaces.
71. Question
Category: Physiological Adaptation
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
A. Acute pain related to biologic and chemical factors
B. Anxiety related to change in or threat to health status
C. Hopelessness related to deteriorating physiological condition
D. Risk for Side effects related to medical therapy
,Correct Answer: A. Acute pain related to biologic and chemical factors
The priority for interdisciplinary care for the patient experiencing a migraine headache is pain
management.
72. Question
Category: Health Promotion and Maintenance
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Whi ch key
items should be included in the teaching plan? Select all that apply.
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
C. Abortive therapy is aimed at eliminating the pain during the aura.
D. A potential side effect of medications is rebound headache.
E. Complementary therapies such as relaxation may be helpful.
F. Continue taking estrogen as prescribed by your physician.
Correct Answer: A, B, C, D, & E.
The client should be counseled on the food and drugs that are allowed. He should also be educated
about the side effects of the medications given. Methods of distraction from pain should also be
included in the teaching plan.
73. Question
Category: Management of Care
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to
the nursing assistant?
A. Document the seizure
B. Perform neurologic checks
C. Take the patient’s vital signs
D. Restrain the patient for protection
Correct Answer: C. Take the patient’s vital signs.
Taking vital signs is within the education and scope of practice for a nursing assistant.
, 74. Question
Category: Management of Care
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you
delegate to LPN/LVN?
A. Complete admission assessment
B. Set up oxygen and suction equipment
C. Place a padded tongue blade at the bedside
D. Pad the side rails before the patient arrives
Correct Answer: B. Set up oxygen and suction equipment
The LPN/LVN can set up the equipment for oxygen and suction.
75. Question
Category: Health Promotion and Maintenance
A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For
which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”
B. “Wear your medical alert bracelet at all times.”
C. “Protect your loved one’s airway during a seizure.”
D. “It’s OK to take over-the-counter medications.”
Correct Answer: D. “It’s OK to take over-the-counter medications.”
A patient with a seizure disorder should not take over-the-counter medications without consulting with
the physician first.
1. A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and
pale. Which of the following tests is most likely to be performed first?
A. Blood sugar check
B. CT scan
C. Blood cultures
Correct Answers/ Rationale (2022 update)
65. Question
Category: Psychosocial Integrity
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most
likely affect the behavior?
A. Strange bed and surroundings.
B. Separation from parents.
C. Presence of other toddlers.
D. Unfamiliar toys and games.
Correct Answer: B. Separation from parents
Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed
on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to
withstand other stress.
66. Question
Category: Psychosocial Integrity
While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive
development at this age?
A. They are able to make simple associations of ideas.
B. They are able to think logically in organizing facts.
C. Interpretation of events originates from their own perspective.
D. Conclusions are based on previous experiences.
Correct Answer: B. They are able to think logically in organizing facts.
The child in the concrete operational stage, according to Piaget, is capable of mature thought when
allowed to manipulate and organize objects.
67. Question
,Category: Psychosocial Integrity
The nurse has just admitted a client with severe depression. From which focus should the nurse identify
a priority nursing diagnosis?
A. Nutrition
B. Elimination
C. Activity
D. Safety
Correct Answer: D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the
plan. Depression can be effectively treated in primary care setti ngs using an evidence-based
collaborative approach in which primary care providers are systematically supported by mental health
providers in caring for a caseload of patients.
68. Question
Category: Safety and Infection Control
Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized
children?
A. Sports and games with rules
B. Finger paints and water play.
C. “Dress-up” clothes and props.
D. Chess and television programs
Correct Answer: A. Sports and games with rules
The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical reasoning and
social skills are developed through play.
69. Question
Category: Health Promotion and Maintenance
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family
suggests they encourage the client to rest frequently in which of the following positions?
A. High Fowler’s
,B. Supine
C. Left lateral
D. Low Fowler’s
Correct Answer: A. High Fowler’s
Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac workload and
facilitates breathing.
70. Question
Category: Physiological Adaptation
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will
indicate that the child has adequate fluid replacement is:
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn
Correct Answer: A. Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium -
ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and
cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These
mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary
permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic
solutes, and plasma proteins between the intravascular and interstitial spaces.
71. Question
Category: Physiological Adaptation
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
A. Acute pain related to biologic and chemical factors
B. Anxiety related to change in or threat to health status
C. Hopelessness related to deteriorating physiological condition
D. Risk for Side effects related to medical therapy
,Correct Answer: A. Acute pain related to biologic and chemical factors
The priority for interdisciplinary care for the patient experiencing a migraine headache is pain
management.
72. Question
Category: Health Promotion and Maintenance
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Whi ch key
items should be included in the teaching plan? Select all that apply.
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
C. Abortive therapy is aimed at eliminating the pain during the aura.
D. A potential side effect of medications is rebound headache.
E. Complementary therapies such as relaxation may be helpful.
F. Continue taking estrogen as prescribed by your physician.
Correct Answer: A, B, C, D, & E.
The client should be counseled on the food and drugs that are allowed. He should also be educated
about the side effects of the medications given. Methods of distraction from pain should also be
included in the teaching plan.
73. Question
Category: Management of Care
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to
the nursing assistant?
A. Document the seizure
B. Perform neurologic checks
C. Take the patient’s vital signs
D. Restrain the patient for protection
Correct Answer: C. Take the patient’s vital signs.
Taking vital signs is within the education and scope of practice for a nursing assistant.
, 74. Question
Category: Management of Care
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you
delegate to LPN/LVN?
A. Complete admission assessment
B. Set up oxygen and suction equipment
C. Place a padded tongue blade at the bedside
D. Pad the side rails before the patient arrives
Correct Answer: B. Set up oxygen and suction equipment
The LPN/LVN can set up the equipment for oxygen and suction.
75. Question
Category: Health Promotion and Maintenance
A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For
which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”
B. “Wear your medical alert bracelet at all times.”
C. “Protect your loved one’s airway during a seizure.”
D. “It’s OK to take over-the-counter medications.”
Correct Answer: D. “It’s OK to take over-the-counter medications.”
A patient with a seizure disorder should not take over-the-counter medications without consulting with
the physician first.
1. A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and
pale. Which of the following tests is most likely to be performed first?
A. Blood sugar check
B. CT scan
C. Blood cultures
