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NCLEX-RN Exam Questions - Part 101
1. A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?
A) TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.
B) TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.
C) TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.
D) TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.
2. A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed.Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
A) Phantom pain is entirely in the client - s mind. The client should be instructed that the pain is psychological and should not be treated.
B) The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
C) The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
D) Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
3. A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the clients return to her room, which nursing measure best demonstrates the nurses thorough understanding of possible postthyroidectomy complications?
A) Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
B) Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
C) A tracheostomy set, O2, and suction are available at the bedside.
D) The nurse should instruct the client as soon as possible on alternative means of communication.
4. A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the clients symptoms, nursing assessment would focus on:
A) Detection of tetany
B) Detection of hypocalcemia to prevent seizures
C) Evidence of depression
D) Detection of premature cataract formation
5. A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wifes home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow.As far as the insulin, isn - t a fellow allowed to forget now and then?' The client - s actions and response best demonstrate:
A) Depression
B) Anger
C) Denial
D) Bargaining
A) TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.
B) TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.
C) TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.
D) TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.
2. A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed.Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
A) Phantom pain is entirely in the client - s mind. The client should be instructed that the pain is psychological and should not be treated.
B) The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
C) The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
D) Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
3. A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the clients return to her room, which nursing measure best demonstrates the nurses thorough understanding of possible postthyroidectomy complications?
A) Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
B) Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
C) A tracheostomy set, O2, and suction are available at the bedside.
D) The nurse should instruct the client as soon as possible on alternative means of communication.
4. A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the clients symptoms, nursing assessment would focus on:
A) Detection of tetany
B) Detection of hypocalcemia to prevent seizures
C) Evidence of depression
D) Detection of premature cataract formation
5. A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wifes home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow.As far as the insulin, isn - t a fellow allowed to forget now and then?' The client - s actions and response best demonstrate:
A) Depression
B) Anger
C) Denial
D) Bargaining
1. Right Answer: C
Explanation: (A) TENS units do not have this effect, but whirlpool therapy does. (B) TENS units do not produce endogenous opioids, only the body can do that. (C) TENS units do work based on the gatecontrol theory of pain control. (D) TENS units do not have this effect, but possibly changing the clients position would.
2. Right Answer: B
Explanation: (A) This statement is entirely false. (B) Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. (C) Although the cause of phantom pain is still unknown, thesemeasures may promote the relief of any type of pain, not just phantom pain. (D) Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
3. Right Answer: C
Explanation: (A) Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. (C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
4. Right Answer: A
Explanation: (A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D)Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.
5. Right Answer: C
Explanation: (A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the clients actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the clients actions or verbal response.
Explanation: (A) TENS units do not have this effect, but whirlpool therapy does. (B) TENS units do not produce endogenous opioids, only the body can do that. (C) TENS units do work based on the gatecontrol theory of pain control. (D) TENS units do not have this effect, but possibly changing the clients position would.
2. Right Answer: B
Explanation: (A) This statement is entirely false. (B) Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. (C) Although the cause of phantom pain is still unknown, thesemeasures may promote the relief of any type of pain, not just phantom pain. (D) Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
3. Right Answer: C
Explanation: (A) Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. (C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
4. Right Answer: A
Explanation: (A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D)Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.
5. Right Answer: C
Explanation: (A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the clients actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the clients actions or verbal response.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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