RN NCLEX Questions And Verified
Correct Answers
A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes
mellitus and reports difficulty following the diet and remembering to take the prescribed
medication.
Which of the following actions should the nurse take to promote client compliance?
(SATA)
A. Ask the dietitian to assist with meal planning
B. Contact the client's support system
C. Assess for age-related cognitive awareness
D. Encourage the use of a daily medication dispenser
E. Provide educational materials for home use - Correct Answer-A, B, D, E
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the
basis of this test result, the nurse plans to teach the client about the need for which
measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia - Correct Answer-D
Rationale:
The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This
test measures the amount of glucose that has become permanently bound to the red
blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback
about blood glucose for the past 120 days. Elevations in the blood glucose level will cause
elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who
have periods of hyperglycemia that are undetected in other ways. The estimated average
glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L).
Elevations indicate continued need for teaching related to the prevention of
hyperglycemic episodes.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The
nurse should explain that which is the best time to perform this exam?
A. After a shower or bath
,B. While standing to void
C. After having a bowel movement
D. While lying in bed before arising - Correct Answer-A
Rationale:
The nurse needs to teach the client how to perform a TSE. The nurse should instruct the
client to perform the exam on the same day each month. The nurse should also instruct
the client that the best time to perform a TSE is after a shower or bath when the hands
are warm and soapy and the scrotum is warm. Palpation is easier and the client will be
better able to identify any abnormalities. The client would stand to perform the exam, but
it would be difficult to perform the exam while voiding. Having a bowel movement is
unrelated to performing a TSE.
The clinic nurse prepares to perform a focused assessment on a client who is complaining
of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for
this type of assessment? Select all that apply.
A. Auscultating lung sounds
B. Obtaining the client's temperature
C. Assessing the strength of peripheral pulses
D. Obtaining information about the client's respirations
E. Performing a musculoskeletal and neurological examination
F. Asking the client about a family history of any illness or disease - Correct Answer-A, B,
D
Rationale:
A focused assessment focuses on a limited or short-term problem, such as the client's
complaint. Because the client is complaining of symptoms of a cold, a cough, and lung
congestion, the nurse would focus on the respiratory system and the presence of an
infection. A complete assessment includes a complete health history and physical
examination and forms a baseline database. Assessing the strength of peripheral pulses
relates to a vascular assessment, which is not related to this client's complaints. A
musculoskeletal and neurological examination also is not related to this client's
complaints. However, strength of peripheral pulses and a musculoskeletal and
neurological examination would be included in a complete assessment. Likewise, asking
the client about a family history of any illness or disease would be included in a complete
assessment.
,The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral
development with a parent. The nurse should tell the parent that which factor motivates
good and bad actions for the child at the preconventional level?
A. Peer pressure
B. Social pressure
C. Parents' behavior
D. Punishment and reward - Correct Answer-D
Rationale:
In the preconventional stage, morals are thought to be motivated by punishment and
reward. If the child is obedient and is not punished, then the child is being moral. The
child sees actions as good or bad. If the child's actions are good, the child is praised. If
the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated
factors for this stage of moral development.
The maternity nurse is providing instructions to a new mother regarding the psychosocial
development of the newborn infant. Using Erikson's psychosocial development theory,
the nurse instructs the mother to take which measure?
A. Allow the newborn infant to signal a need.
B. Anticipate all needs of the newborn infant.
C. Attend to the newborn infant immediately when crying.
D. Avoid the newborn infant during the first 10 minutes of crying. - Correct Answer-A
Rationale:According to Erikson, the caregiver should not try to anticipate the newborn
infant's needs at all times but must allow the newborn infant to signal needs. If a newborn
infant is not allowed to signal a need, the newborn will not learn how to control the
environment. Erikson believed that a delayed or prolonged response to a newborn infant's
signal would inhibit the development of trust and lead to mistrust of others.
A nursing student is presenting a clinical conference to peers regarding Freud's
psychosexual stages of development, specifically the anal stage. The student explains to
the group that which characteristic relates to the anal stage?
A. This stage is associated with toilet training.
B. This stage is characterized by the gratification of self.
C. This stage is characterized by a tapering off of conscious biological and sexual urges.
D. This stage is associated with pleasurable and conflicting feelings about the genital
organs. - Correct Answer-A
, Rationale:
In general, toilet training occurs during the anal stage. According to Freud, the child gains
pleasure from the elimination of feces and from their retention. Option 2 relates to the oral
stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage.
The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff.
The nurse should tell that staff that which child behavior is characteristic of the formal
operations stage?
A. The child has the ability to think abstractly.
B. The child begins to understand the environment.
C. The child is able to classify, order, and sort facts.
D. The child learns to think in terms of past, present, and future. - Correct Answer-A
Rationale:
In the formal operations stage, the child has the ability to think abstractly and logically.
Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational
stage. Option 4 identifies the preoperational stage.
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the
child because the child seems to be more attentive to friends than anything else. Using
Erikson's psychosocial development theory, the nurse should make which response?
A. "You need to be concerned."
B. "You need to monitor the child's behavior closely."
C. "At this age, the child is developing his own personality."
D. "You need to provide more praise to the child to stop this behavior." - Correct Answer-
C
Rationale:According to Erikson, during school-age years (6 to 12 years of age), the child
begins to move toward peers and friends and away from the parents for support. The
child also begins to develop special interests that reflect his or her own developing
personality instead of the parents'. Therefore, options 1, 2, and 4 are incorrect responses.
The nurse educator is preparing to conduct a teaching session for the nursing staff
regarding the theories of growth and development and plans to discuss Kohlberg's theory
of moral development. What information should the nurse include in the session? Select
all that apply
Correct Answers
A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes
mellitus and reports difficulty following the diet and remembering to take the prescribed
medication.
Which of the following actions should the nurse take to promote client compliance?
(SATA)
A. Ask the dietitian to assist with meal planning
B. Contact the client's support system
C. Assess for age-related cognitive awareness
D. Encourage the use of a daily medication dispenser
E. Provide educational materials for home use - Correct Answer-A, B, D, E
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the
basis of this test result, the nurse plans to teach the client about the need for which
measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia - Correct Answer-D
Rationale:
The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This
test measures the amount of glucose that has become permanently bound to the red
blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback
about blood glucose for the past 120 days. Elevations in the blood glucose level will cause
elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who
have periods of hyperglycemia that are undetected in other ways. The estimated average
glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L).
Elevations indicate continued need for teaching related to the prevention of
hyperglycemic episodes.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The
nurse should explain that which is the best time to perform this exam?
A. After a shower or bath
,B. While standing to void
C. After having a bowel movement
D. While lying in bed before arising - Correct Answer-A
Rationale:
The nurse needs to teach the client how to perform a TSE. The nurse should instruct the
client to perform the exam on the same day each month. The nurse should also instruct
the client that the best time to perform a TSE is after a shower or bath when the hands
are warm and soapy and the scrotum is warm. Palpation is easier and the client will be
better able to identify any abnormalities. The client would stand to perform the exam, but
it would be difficult to perform the exam while voiding. Having a bowel movement is
unrelated to performing a TSE.
The clinic nurse prepares to perform a focused assessment on a client who is complaining
of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for
this type of assessment? Select all that apply.
A. Auscultating lung sounds
B. Obtaining the client's temperature
C. Assessing the strength of peripheral pulses
D. Obtaining information about the client's respirations
E. Performing a musculoskeletal and neurological examination
F. Asking the client about a family history of any illness or disease - Correct Answer-A, B,
D
Rationale:
A focused assessment focuses on a limited or short-term problem, such as the client's
complaint. Because the client is complaining of symptoms of a cold, a cough, and lung
congestion, the nurse would focus on the respiratory system and the presence of an
infection. A complete assessment includes a complete health history and physical
examination and forms a baseline database. Assessing the strength of peripheral pulses
relates to a vascular assessment, which is not related to this client's complaints. A
musculoskeletal and neurological examination also is not related to this client's
complaints. However, strength of peripheral pulses and a musculoskeletal and
neurological examination would be included in a complete assessment. Likewise, asking
the client about a family history of any illness or disease would be included in a complete
assessment.
,The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral
development with a parent. The nurse should tell the parent that which factor motivates
good and bad actions for the child at the preconventional level?
A. Peer pressure
B. Social pressure
C. Parents' behavior
D. Punishment and reward - Correct Answer-D
Rationale:
In the preconventional stage, morals are thought to be motivated by punishment and
reward. If the child is obedient and is not punished, then the child is being moral. The
child sees actions as good or bad. If the child's actions are good, the child is praised. If
the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated
factors for this stage of moral development.
The maternity nurse is providing instructions to a new mother regarding the psychosocial
development of the newborn infant. Using Erikson's psychosocial development theory,
the nurse instructs the mother to take which measure?
A. Allow the newborn infant to signal a need.
B. Anticipate all needs of the newborn infant.
C. Attend to the newborn infant immediately when crying.
D. Avoid the newborn infant during the first 10 minutes of crying. - Correct Answer-A
Rationale:According to Erikson, the caregiver should not try to anticipate the newborn
infant's needs at all times but must allow the newborn infant to signal needs. If a newborn
infant is not allowed to signal a need, the newborn will not learn how to control the
environment. Erikson believed that a delayed or prolonged response to a newborn infant's
signal would inhibit the development of trust and lead to mistrust of others.
A nursing student is presenting a clinical conference to peers regarding Freud's
psychosexual stages of development, specifically the anal stage. The student explains to
the group that which characteristic relates to the anal stage?
A. This stage is associated with toilet training.
B. This stage is characterized by the gratification of self.
C. This stage is characterized by a tapering off of conscious biological and sexual urges.
D. This stage is associated with pleasurable and conflicting feelings about the genital
organs. - Correct Answer-A
, Rationale:
In general, toilet training occurs during the anal stage. According to Freud, the child gains
pleasure from the elimination of feces and from their retention. Option 2 relates to the oral
stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage.
The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff.
The nurse should tell that staff that which child behavior is characteristic of the formal
operations stage?
A. The child has the ability to think abstractly.
B. The child begins to understand the environment.
C. The child is able to classify, order, and sort facts.
D. The child learns to think in terms of past, present, and future. - Correct Answer-A
Rationale:
In the formal operations stage, the child has the ability to think abstractly and logically.
Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational
stage. Option 4 identifies the preoperational stage.
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the
child because the child seems to be more attentive to friends than anything else. Using
Erikson's psychosocial development theory, the nurse should make which response?
A. "You need to be concerned."
B. "You need to monitor the child's behavior closely."
C. "At this age, the child is developing his own personality."
D. "You need to provide more praise to the child to stop this behavior." - Correct Answer-
C
Rationale:According to Erikson, during school-age years (6 to 12 years of age), the child
begins to move toward peers and friends and away from the parents for support. The
child also begins to develop special interests that reflect his or her own developing
personality instead of the parents'. Therefore, options 1, 2, and 4 are incorrect responses.
The nurse educator is preparing to conduct a teaching session for the nursing staff
regarding the theories of growth and development and plans to discuss Kohlberg's theory
of moral development. What information should the nurse include in the session? Select
all that apply
