NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 951:

  When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

  A. nausea and vomiting

  B. itching

  C. urinary retention

  D. somnolence

  Correct Answer: B

  A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting

  up to 10 hours.

  Nausea and vomiting might occur 4-7 hours after injection.

  Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the

  first 3 hours.

  Somnolence is a rare side effect.

• Question 952:

  When a middle-age woman says to the nurse, "I'm really worried about menopause. When my mom went through it, she got really depressed."

  The nurse's best response is __________.

  A. "It is a myth that women get depressed because of menopause."

  B. "Menopause is a normal developmental process."

  C. "It sounds like you are worried that you might become depressed during menopause."

  D. "When women experience depression during menopause it is usually because of social stresses."

  Correct Answer: C

  Choice "It sounds like you are worried that you might become depressed during menopause." not only acknowledges the client's fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman's unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn't care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn't think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice "When women experience depression during menopause it is usually because of social stresses." is true but is a nontherapeutic response in this situation.

• Question 953:

  All of the following are clinical manifestations indicating male climacteric except __________.

  A. hot flashes

  B. loss of reproductive ability

  C. headaches

  D. heart palpitations

  Correct Answer: B

  The likelihood of fathering children does decrease with aging and decreased testosterone production, but men do not lose their ability to reproduce during the climacteric. Many men do not experience any physical symptoms of climacteric but some men do report hot flashes, headaches, and heart palpitations, among other symptoms.

• Question 954:

  When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?

  A. dermabrasion

  B. rhinoplasty

  C. blepharoplasty

  D. rhytidectomy

  Correct Answer: D

  Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a

  face-lift.

  Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded

  with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from

  tattoos.

  Rhinoplasty is performed to improve the appearance of the nose and involves reshaping the nasal

  skeleton and overlying skin.

  Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.

• Question 955:

  After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?

  A. breast tenderness

  B. weight gain

  C. fluid retention

  D. uterine bleeding

  Correct Answer: D

  Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.

• Question 956:

  When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except __________.

  A. Hypoglycemia in diabetic women.

  B. The possible return of monthly menses when taking combination hormones.

  C. Increased risk of gallbladder disease.

  D. Increased risk of breast, cervical, and ovarian cancer with long-term use.

  Correct Answer: A

  When taking estrogen, there is an increased risk of diabetes or hyperglycemia due to lowered glucose

  tolerance.

  It is true that monthly menses might return when taking combination hormones. The progestin is

  responsible for this.

  There is also a risk of gallbladder disease.

  It is also true that there is an increased risk of breast, cervical, and ovarian cancer with long-term hormone

  replacement therapy.

• Question 957:

  Which cranial nerves assesses the gag reflex test?

  A. IX and X

  B. V and VII

  C. IX and XII

  D. V and X

  Correct Answer: A

  Gagging during the gag reflex test indicates that cranial nerves IX and X (the glossopharyngeal and vagus nerves) are intact.

• Question 958:

  To improve overall health, the nurse should place highest priority on assisting a client to make lifestyle changes for which of the following habits?

  A. drinking a six-pack of beer each day

  B. eating an occasional chocolate bar

  C. exercising twice a week

  D. using relaxation exercises to deal with stress

  Correct Answer: A

  Health promotion is motivated by the desire to increase people's well-being and health potential. The nurse promotes health by maximizing the client's own strengths. Identification and analysis of the client's strengths are a component of preventing illness, restoring health, and facilitating coping with disability or death. The nurse facilitates decisions about lifestyle that enhance one's quality of life and encourage acceptance of responsibility for one's own health.

• Question 959:

  A client asks the nurse what risk factors increase the chances of getting skin cancer.

  The risk factors include all except __________.

  A. light or fair complexion.

  B. exposure to sun for great periods of time.

  C. certain diet and foods.

  D. history of bad sunburns.

  Correct Answer: C

  Conditions that increase risks for skin cancer are: light or fair complexion, history of having bad sunburns or scars from previous burns, personal or family history of skin cancer, frequently working or playing outdoors with exposure to the sun, exposure to X-rays or radiation, exposure to certain chemicals through work or hobbies (coal, pitch, asphalt, petroleum), repeated trauma or injury to an area resulting in scars, older than age 50, male gender, and living in a geographic location near the equator or at high altitudes. Ways to prevent skin cancer are avoiding exposure to the sun, wearing a hat to protect the face, avoiding all sun lamps, and using a sunscreen with a minimum of 15 sun protection factor (SPF) if exposure to the sun is unavoidable. Teaching clients how to recognize a potential problem involves inspecting the skin frequently; noting all birthmarks, freckles, and moles; and seeking medical assistance if any of the following are noted: change in color, change in shape, change in surface texture, change in size, change in the surrounding skin, or a new mole or a sore that does not heal.

• Question 960:

  Which of the following vaccines are not part of the regular schedule of immunizations for children?

  A. DTaP

  B. MMR

  C. Hib

  D. hepatitis A

  Correct Answer: D

  Hepatitis A is not part of the regular immunization schedule for children. DTaP, MMR, and Hib are all regularly scheduled vaccines for children.