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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 60 )

Updated On: 26-Jan-2026
Page 60 of 345
PDF with 862 Questions

A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?

  1. Somatic
  2. Grandiose
  3. Persecutory
  4. Nihilistic

Answer(s): B

Explanation:

(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence.



When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?

  1. Phentolamine (Regitine)
  2. Epinephrine
  3. Phenylephrine (Neo-Synephrine)
  4. Sodium bicarbonate

Answer(s): A

Explanation:

(A) Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. (B) Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. (C) Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. (D) Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.



A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

  1. Dizziness and tachypnea
  2. Circumoral pallor and lightheadedness
  3. Headache and facial flushing
  4. Pallor and itching of the face and neck

Answer(s): C

Explanation:

(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.



A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

  1. Responsive to touch, wants to be held
  2. Uncomforted by touch, refuses bottle
  3. Maintains eye-to-eye contact
  4. Finicky eater, easily pacified, cuddly

Answer(s): B

Explanation:

(A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact.



Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

  1. Increased core body temperature
  2. Decreased serum osmolality
  3. Administration of hypo-osmolar fluids
  4. Decreased PaCO2

Answer(s): D

Explanation:

(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.



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