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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 52 )

Updated On: 12-Jan-2026
Page 52 of 345
PDF with 862 Questions

What is the most effective method to identify early breast cancer lumps?

  1. Mammograms every 3 years
  2. Yearly checkups performed by physician
  3. Ultrasounds every 3 years
  4. Monthly breast self-examination

Answer(s): D

Explanation:

(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.



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 3­4 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?

  1. Short, polite responses to interview questions
  2. Introspection related to his present situation
  3. Exaggerated self-importance
  4. Feelings of helplessness and hopelessness

Answer(s): 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.



When the nurse is evaluating lab data for a client 18­24 hours after a major thermal burn, the expected physiological changes would include which of the following?

  1. Elevated serum sodium
  2. Elevated serum calcium
  3. Elevated serum protein
  4. Elevated hematocrit

Answer(s): D

Explanation:

(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemi
A. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.



A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

  1. Provide him with a safe and structured environment.
  2. Assist him to develop more effective coping mechanisms.
  3. Have him sign a "no-suicide" contract.
  4. Isolate him from stressful situations that may precipitate a depressive episode.

Answer(s): B

Explanation:

(A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short-term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.



During burn therapy, morphine is primarily administered IV for pain management because this route:

  1. Delays absorption to provide continuous pain relief
  2. Facilitates absorption because absorption from muscles is not dependable
  3. Allows for discontinuance of the medication if respiratory depression develops
  4. Avoids causing additional pain from IM injections

Answer(s): B

Explanation:

(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration.



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