Free Practice Questions for NCLEX NCLEX-PN Exam

Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable.Reduction of Risk Potential

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.Health Promotion and Maintenance

Acute Pain is most appropriate for the client experiencing acute pancreatitis.Physiological Adaptation

Choice 3 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 4 is true but is a nontherapeutic response in this situation.Health Promotion and Maintenance

Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.Basic Care and Comfort

Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.Physiological Adaptation

Preparing a client’s room environment should include making the client’s bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client’s hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.Basic

Care and Comfort

Home sources of iron that can be absorbed in the body include meat, poultry, and fish. In addition, these sources contain a factor that helps to enhance iron absorption of nonheme sources. Eating Vitamin C at the same time as iron sources also helps to promote iron absorption.High calcium intake in the diet promotes the absorption of iron because it helps to bind to phytates and thereby limits their effect.Physiological Adaptation

The client needs to wash his hair to remove hair spray, cream, or oil that might interfere with attaching the electrodes to the scalp. Food or fluids do not need to be restricted, with the exception of caffeinated fluids. There is no restriction on metal objects. Aspirin is not a medication that needs to be held before the test (just anticonvulsants, tranquilizers, barbiturates, and other sedatives).Reduction of Risk Potential

All of the choices are functions of the kidneys except reabsorbing waste products. The kidneys excrete waste products.Physiological Adaptation

Leptin (recessive obesity gene—protein hormone) is expressed in fat cell coding for the protein that reacts to the percentage of fat cells in the body. Leptin is associated with increased energy expenditure and decreased food intake via hypothalamic control. Obese clients might have insensitivity or resistance to the effects of leptin. Leptin can affect other body hormones such as insulin. Genetic factors include leptin, uncoupling proteins, and the amount of brown/white fat in the body.Physiological Adaptation

There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.Basic Care and

Comfort

Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally.Safety and Infection Control

Dyskinesia is an impairment of the ability to execute voluntary muscles.Physiological Adaptation

All clients must be treated with dignity. Rather than a strategy, treating clients with dignity is a basic core

value universal to nursing.Psychosocial Integrity