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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 24 )

Updated On: 12-Jan-2026
Page 24 of 345
PDF with 862 Questions

In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:

  1. Explain the side effects of the medication
  2. Discuss the danger of overmedication
  3. Distribute written material to supplement verbal instructions
  4. Explore the client's perception regarding medication therapy

Answer(s): D

Explanation:

(A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. (D) The first step in the teaching process is to determine the client's perception.



A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?

  1. Marked elevation in blood pressure, respirations, and pulse
  2. Decreased systolic pressure, cold skin, and anuria
  3. Rapid pulse; narrowed pulse pressure; cool, moist skin
  4. No urinary output, tachycardia, and restlessness

Answer(s): C

Explanation:

(A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock.



A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:

  1. Two to 4 hours after the last drink
  2. Six to 8 hours after the last drink
  3. Immediately on admission
  4. Twenty-four hours after the last drink

Answer(s): B

Explanation:

(A) This answer is incorrect. Alcohol withdrawal usually begins approximately 6­8 hours after the last drink. (B) This answer is correct. It takes approximately 6­8 hours for metabolism of alcohol. (C) This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. (D) This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6­8 hours of the last drink.



A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:

  1. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened
  2. Marked engorgement and breast pain
  3. Elevated temperature and general malaise
  4. Cracked nipple with complaints of soreness

Answer(s): A

Explanation:

(A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain. This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis. (D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.



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 client's symptoms, nursing assessment would focus on:

  1. Detection of tetany
  2. Detection of hypocalcemia to prevent seizures
  3. Evidence of depression
  4. Detection of premature cataract formation

Answer(s): 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.



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