NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM COMPLETE 300 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM
COMPLETE 300 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
1
QUESTION 11
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2
months, his family describes him as being ―on the move,‖ sleeping
3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial
assessment with the client, the nurse would expect him to exhibit which of the following?
A. Short, polite responses to interview questions
B. Introspection related to his present situation
C. Exaggerated self-importance
D. Feelings of helplessness and hopelessness
Answer: C
Explanation:
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward
authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of
ideas, which prevents concentration.
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of
helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
QUESTION 12
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality.
When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy
is:
A. 70 mg/dL and 120 mg/dL
B. 100 mg/dL and 200 mg/dL
C. 40 mg/dL and 130 mg/dL
D. 90 mg/dL and 200 mg/dL
A+
Answer: A
Explanation:
(A) The recommended range is 70–120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels
are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can
also have detrimental effects on the fetus.
QUESTION 13
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between
neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:
A. In neurogenic shock, the skin is warm and dry
B. In hypovolemic shock, there is a bradycardia
C. In hypovolemic shock, capillary refill is less than 2 seconds
D. In neurogenic shock, there is delayed capillary refill
Answer: A
Explanation:
(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This
loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to
parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In
neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock,
the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would
be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral
flow is good.
QUESTION 14
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored
stools. His admitting diagnosis is ―rule out hepatitis.‖ Laboratory studies reveal elevated liver enzymes and
bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?