NCLEX Practice Exam 31 (10 Questions)

1. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

Chronic fatigue syndrome

Normal aging

Sundowning

Delusions

Increased confusion at night is known as “sundowning” syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore. answer B is incorrect. A delusion is a firm. fixed belief; therefore. answer D is incorrect.

Explanation

Increased confusion at night is known as “sundowning” syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore. answer B is incorrect. A delusion is a firm. fixed belief; therefore. answer D is incorrect.

2. A client with a diagnosis of HPV is at risk for which of the following?

Hodgkin’s lymphoma

Cervical cancer

Multiple myeloma

Ovarian cancer

The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A. C. and D. so those are incorrect.

Explanation

The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A. C. and D. so those are incorrect.

3. During the initial interview. the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

Syphilis

Herpes

Gonorrhea

Condylomata

A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful. so answer A is incorrect. Condylomata lesions are painless warts. so answer D is incorrect. In answer C. gonorrhea does not present as a lesion. but is exhibited by a yellow discharge.

Explanation

A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful. so answer A is incorrect. Condylomata lesions are painless warts. so answer D is incorrect. In answer C. gonorrhea does not present as a lesion. but is exhibited by a yellow discharge.

4. A client is admitted to the labor and delivery unit in active labor. During examination. the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

Document the finding

Report the finding to the doctor

Prepare the client for a C-section

Continue primary care as prescribed

Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding. so answer A is incorrect. The physician must make the decision to perform a C-section. making answer C incorrect. It is not enough to continue primary care. so answer D is incorrect.

Explanation

Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding. so answer A is incorrect. The physician must make the decision to perform a C-section. making answer C incorrect. It is not enough to continue primary care. so answer D is incorrect.

5. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

Elevated blood glucose

Elevated platelet count

Elevated creatinine clearance

Elevated hepatic enzymes

The criteria for HELLP is hemolysis. elevated liver enzymes. and low platelet count. In answer A. an elevated blood glucose level is not associated with HELLP. Platelets are decreased. not elevated. in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.

Explanation

The criteria for HELLP is hemolysis. elevated liver enzymes. and low platelet count. In answer A. an elevated blood glucose level is not associated with HELLP. Platelets are decreased. not elevated. in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.

6. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

Pain on flexion of the hip and knee

Nuchal rigidity on flexion of the neck

Pain when the head is turned to the left side

Dizziness when changing positions

Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

Explanation

Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

7. The client with confusion says to the nurse. "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

“You know you had breakfast 30 minutes ago.”

“I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”

“I’ll get you some juice and toast. Would you like something else?”

“You will have to wait a while; lunch will be here in a little while.”

The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

Explanation

The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

8. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

Venereal Disease Research Lab (VDRL)

Rapid plasma reagin (RPR)

Florescent treponemal antibody (FTA)

Thayer-Martin culture (TMC)

Fluorescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis. so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea. so answer D is incorrect.

Explanation

Fluorescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis. so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea. so answer D is incorrect.

9. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

Agnosia

Apraxia

Anomia

Aphasia

Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension. anomia is the inability to find words. and aphasia is the inability to speak or understand so answers A. C. and D are incorrect.

Explanation

Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension. anomia is the inability to find words. and aphasia is the inability to speak or understand so answers A. C. and D are incorrect.

10. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

Urinary incontinence

Headaches

Confusion

Nausea

Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity. dizziness. unsteadiness. and clumsiness. The client might already be experiencing urinary incontinence or headaches. but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore. answers A. B. and C are incorrect.

Explanation

Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity. dizziness. unsteadiness. and clumsiness. The client might already be experiencing urinary incontinence or headaches. but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore. answers A. B. and C are incorrect.