NCLEX QUESTIONS

1) The nurse makes the following entry on an el erly !lient"s !are #lan$ %&oal not met' Client refuses to am(ulate$ stating$ )I am too afrai I will fall"*' The nurse shoul take whi!h of the following a!tions+ ,1) Notify the #hysi!ian ,-) .eassign the !lient to another nurse' ,/) .ee0amine the nursing or ers' ,1) 2rite a new nursing iagnosis' -) 2hi!h of the following nursing iagnoses woul most likely (e asso!iate with the a(sen!e of hair on a 345year5ol male !lient"s legs+ ,1) 6ltere nutrition7 less than (o y re8uirements' ,-) .isk for infe!tion ,/) 9lui :olume efi!it ,1) Tissue #erfusion$ altere 7 #eri#heral /) 6 nurse is #re#aring to !om#lete an a mission assessment on a !lient that is #artially hearing im#aire ' The (est a##roa!h woul (e to o whi!h of the following+ ,1) .e8uest that a family mem(er (e #resent' ,-) ;re#are written 8uestions that !o:er the assessment !riteria' ,/) S#eak slowly in a low5#it!he :oi!e while fa!ing the !lient' ,1) ;erform the #hysi!al assessment only at this time' 1) 6n el erly$ terminally ill !lient is (eing !are for (y her only aughter' The aughter e0#resses a fear of not knowing how to !are for her mother a##ro#riately' 2hi!h nursing iagnosis is most a##ro#riate+ ,1) So!ial isolation ,-) ;owerlessness ,/) Situational low self5esteem ,1) 6ltere role #erforman!e <) 6 3=5year5ol !lient is a mitte to the hos#ital' The nursing assessment yiel s the following #ro(lems' 2hi!h of these #ro(lems is relate to aging+ ,1) >y#ero#ia ,-) Con u!ti:e hearing loss ,/) ;res(y!usis ,1) Tinnitus =) ;ain in the el erly re8uires !areful assessment (e!ause ol er #eo#le ha:e whi!h of the following !hara!teristi!s+ ,1) In!rease #ain toleran!e ,-) ?e!rease #ain toleran!e ,/) 6re likely to e0#erien!e !hroni! #ain ,1) E0#erien!e re u!e sensory #er!e#tion

3) 6 nurse is working in a geriatri! s!reening !lini!' The nurse woul e0#e!t that the skin of the normal el erly !lient will emonstrate whi!h of the following !hara!teristi!s+ ,1) ?ehy ration !ausing the skin to swell' ,-) @oist skin turgor ,/) Skin turgor showing a loss of elasti!ity' ,1) O:erhy ration !ausing the skin to wrinkle A) 6 3A5year5ol :isually im#aire !lient is a mitte to the nursing unit' 2hi!h of the following inter:entions woul (e most a##ro#riate in re u!ing sensory e#ri:ation+ ,1) Close !urtains to re u!e glare' ,-) Bee# oors o#en to #ro:i e (right light into the room ,/) Bee# !urtains o#en to allow the sun to shine (rightly in the room ,1) Bee# lights in the room imme ' C) 2hi!h of the following are asso!iate with the aging #ro!ess' Choose all that a##ly' ,1) In!rease :isual im#airment ,-) In!rease !alorie re8uirements ,/) ?e!rease sensation to heat an !ol ,1) ?e!rease su(!utaneous fat