Hessy & Saunders NCLEX Questions (use fill in the blank)
1. C: After patient accidentally places glass on edge of counter and it crashes to
the floor, to follow up this situation, which technique will provide the most useful
data?"
A. Mini mental status exam.
B. Vital signs and level of conciousness.
C. Visual field and depth perception.
D. Pupil size and accomodation.
2. D: PN notes patient is pleasant and nods his head in agreement with all of the
PN's statements, but he does not respond to simple requests. Which characteristic
is best supported by the data available?
A. Situational low self-esteem
B. Disturbed personal identity
C. Acute confusion
D. Disturbed sensory function
3. DE: Upon discharge, PN identifies patien as a risk for injury because of his
visual and auditory sensory deficits. Which actions should the PN implement?
(Select all that apply)
A. Explain thta the patient will be admitted to the acute care center until his
scheduled surgery.
B. Ask the social worker about temporary placementin a long-term care center.
C. Ask the patient about his confidence to safely return home until his scheduled
surgery.
D. Make plans with George and a family member to help him assess his home for
safety hazards. (giving him a home safety checklist)
E. Provide family with outside sources that can aide the family with safety
equipment for the home.
4. CD: Patient becomes very angry when the PN provides the list of home safety
checks, that suggest he remove his throw rugs. He yells "you think I'm a helpless
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, Hessy & Saunders NCLEX Questions (use fill in the blank)
old man and can't take care of myself anymore!" Which actions should the PN
implement? (Select all)
A. Advise the patient that he must gain control of his emotions
B. Reassure the patient that he will not always be helpless.
C. Ask the patient to explain what has made him so angry.
D. Stay in the room with the patient and sit quietly.
E. Change the topic of conversation to another subject.
5. C: The PN interprets the patients angry outburst as an indication that he is
afraid he may become dependent upon others if his sensory deficits continure.
Which problem should be added to the plan of care?
A. Social Isolation
B. Self-care deficit
C. Risk for situational low self-esteem
D. Impaired verbal communication
6. B: What additional reinforcement should the PN provide to reduce the problems
of the patients heightened sense of smell?
A. Encourage the patient's friends to continue cooking meals in his home to
promote socialization.
B. Suggest that the meals be prepared at the friend's homes and then delivered to
the patient's home.
C. Advise George to use aromatherapy to overcome his current aversion to odors.
D. Tell the patient to sniff foods before eating them to provide sensory
stimulation.7. C: The patient reports their fingers often feel numb or like "pins
and needles." Data reveals 3+ radial pulses bilaterally with capillary refill of 1
second. How will the PN document this finding?
A. Altered circulation
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