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NCLEX-PN Exam Questions - Part 98
1. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?
A) 'I should raise him to a sitting position.'
B) 'I should check for a fecal impaction.'
C) 'I should look for a kink in the urinary catheter tubing.'
D) 'I should see whether symptoms worsen.'
2. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
A) sudden onset of headache
B) flushed face
C) hypotension
D) nasal congestion
3. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?
A) 'I should avoid eating foods that produce gas.'
B) 'I should drink more fluids like coffee and cola.'
C) 'I should set a regular schedule for bowel movements.'
D) 'I should sit in an upright position for bowel movements.'
4. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, 'No woman will ever want to marry me now.' Which of the following responses by the nurse is most therapeutic?
A) 'Don - t worry. Maybe you - ll meet a paraplegic woman.'
B) 'There is someone for everyone in this world.'
C) 'You are still an attractive man, even though you can - t walk.'
D) 'Tell me more about your feelings on this issue.'
5. Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, 'Oh, well, I really didn - t want the job anyway.' This is an example of:
A) rationalization.
B) denial.
C) projection.
D) compensation.
A) 'I should raise him to a sitting position.'
B) 'I should check for a fecal impaction.'
C) 'I should look for a kink in the urinary catheter tubing.'
D) 'I should see whether symptoms worsen.'
2. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
A) sudden onset of headache
B) flushed face
C) hypotension
D) nasal congestion
3. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?
A) 'I should avoid eating foods that produce gas.'
B) 'I should drink more fluids like coffee and cola.'
C) 'I should set a regular schedule for bowel movements.'
D) 'I should sit in an upright position for bowel movements.'
4. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, 'No woman will ever want to marry me now.' Which of the following responses by the nurse is most therapeutic?
A) 'Don - t worry. Maybe you - ll meet a paraplegic woman.'
B) 'There is someone for everyone in this world.'
C) 'You are still an attractive man, even though you can - t walk.'
D) 'Tell me more about your feelings on this issue.'
5. Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, 'Oh, well, I really didn - t want the job anyway.' This is an example of:
A) rationalization.
B) denial.
C) projection.
D) compensation.
1. Right Answer: D
Explanation: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a health care provider needs to be notified immediately. The remaining choices are correct; they are all ways to relieve autonomic dysreflexia. Reduction of RiskPotential
2. Right Answer: C
Explanation: Hypotension is not indicative of autonomic dysreflexia; rather, hypertension is a sign of autonomic dysreflexia. The remaining choices are symptoms of autonomic dysreflexia. Reduction of Risk Potential
3. Right Answer: B
Explanation: This statement is incorrect because caffeinated fluids, such as coffee and cola, stimulate fluid loss through urination. Instead, fluids such as water and fruit juices should be taken. The remaining choices indicate correct understanding of bowel management. Reduction of Risk Potential
4. Right Answer: D
Explanation: This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic. Reduction of Risk Potential
5. Right Answer: A
Explanation: This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made. Denial is an unconscious process that ignores the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation is an attempt to make up for a perceived weakness by emphasizing a strong point. Psychosocial Integrity
Explanation: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a health care provider needs to be notified immediately. The remaining choices are correct; they are all ways to relieve autonomic dysreflexia. Reduction of RiskPotential
2. Right Answer: C
Explanation: Hypotension is not indicative of autonomic dysreflexia; rather, hypertension is a sign of autonomic dysreflexia. The remaining choices are symptoms of autonomic dysreflexia. Reduction of Risk Potential
3. Right Answer: B
Explanation: This statement is incorrect because caffeinated fluids, such as coffee and cola, stimulate fluid loss through urination. Instead, fluids such as water and fruit juices should be taken. The remaining choices indicate correct understanding of bowel management. Reduction of Risk Potential
4. Right Answer: D
Explanation: This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic. Reduction of Risk Potential
5. Right Answer: A
Explanation: This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made. Denial is an unconscious process that ignores the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation is an attempt to make up for a perceived weakness by emphasizing a strong point. Psychosocial Integrity
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