NCSBN TEST BANK - FOR THE NCLEXRN &
NCLEX-PN, UPDATED EDITION COMPLETE
QUESTIONS AND ANSWERS WITH
RATIONALE
Question 1
A c. What document should be in guiding the care of this patient?
• patient Self Determination Act
• Physician's treatment orders
• Advance Directives.
• Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This document specifies the patient's wishes
Question 2
You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a
nursing student and yourself. To whom is it appropriate to assign complete care for
• Yourself
• The nursing student
• The licensed vocational nurse
• The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable patient, this care should be performed by an RN for a new
admission. Only tasks that do not require independent judgment should be delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the
following on the initial history and physical assessment?
• Increased temperature and lethargy
,• Rash and restlessness
• Increased sleeping and listlessness
• Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and restlessness.
Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-
up and are consistent with the diagnosis?
• "The child has been listless and has lost weight."
• "Her urine is dark yellow and small in amounts."
• "Clothes are becoming tighter across her abdomen." D+) "We notice
muscle weakness and some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is
tight is significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally
married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse?
• Refuse to see the patient until a parent or legal guardian can be contacted
• Withhold treatment until telephone consent can be obtained from the spouse
• Refer the patient to a community pediatric hospital emergency room
• Assess and treat in the same manner as any adult patient
Review Information: The correct answer is:D) Assess and treat in the same manner as any adult patient.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation,
independent living or service in the military. Therefore, this patient, who is married, has the legal capacity of an
adult.
,Question 6
A newly admitted elderly patient is severely dehydrated. When planning care for this patient, which one of the following
is an appropriate task for an Unlicensed Assistive Personnel (UAP)?
• Obtain a history of fluid loss
• Report output of less than 30 ml/hr
• Monitor response to IV fluids
• Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what
must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be
assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is
related to this diagnosis?
• Diagnosis of chickenpox six months ago
• Exposure to strep throat in daycare last month
• Treatment for ear infection two months ago
• Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in daycare last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic
fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would
indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an
infection has no clinical symptoms.
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative patient, the BEST action by
the nurse is to
, • Discuss the feeling of reluctance with an objective peer or supervisor
• Limit contacts with the patient to avoid reinforcing the manipulative behavior
• Confront the patient regarding the negative effects of his/her behavior on others
• Develop a behavior modification plan that will promote more functional behavior
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The
nurse must attempt to discover attitudes and feelings in the self that influence the nurse- patient relationship.
Question 9
A patient is being treated for paranoid schizophrenia. When the patient became loud and boisterous, the nurse
immediately placed him in seclusion as a precautionary measure. The patient willingly complied. The nurse's action
• May result in charges of unlawful seclusion and restraint
• Leaves the nurse vulnerable for charges of assault and battery
• Was appropriate in view of the patient's history of violence
• Was necessary to maintain the therapeutic milieu of the unit
Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion
should only be used when there is an immediate threat of violence or threatening behavior.
Question 10
A patient has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing
diagnosis should have PRIORITY?
• Pain related to ischemia
• Risk for altered elimination: constipation
• Risk for complication: dysrhythmias
• Anxiety
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