NURS NCLEX RN Exam Questions with Answers 2023/2024 Success Assured, Exams of Nursing

Download NURS NCLEX RN Exam Questions with Answers 2023/2024 Success Assured and more Exams Nursing in PDF only on Docsity! NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The Safe & Effective Care Environment: The Management of Care Practice Questions 1. You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client’s wife, the client states that “my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself” and the wife responds to this statement with, “that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.” How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life? A. You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions. B. You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need. C. You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need. D. You should reinforce the wife’s belief that legally married spouses automatically serve for the other spouse’s durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married Correct Response: A You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions. Both the client and the client’s spouse have knowledge deficits relating to advance directives. Legally married spouses do not automatically serve for the other spouse’s durable power of attorney for health care decisions; others than the spouse can be legally appointed while people NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED are married. 2. The Patient Self Determination Act of the United States protects clients in terms of their rights to what? Select all that apply. A. Privacy and to have their medical information confidential unless the client formally approves the sharing of this information with others such as family members. B. Make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so. C. Be fully informed about all treatments in term of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it D. Make decisions about who their health care provider is without any coercion or undue influence of others including healthcare providers. Correct Response: B,D The Patient Self Determination Act, which was passed by the US Congress in 1990, gives Americans the right to make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so. These decisions can also include rejections for future care and treatment and these decisions are reflect in advance directives. This Act also supports the rights of the client to be free of any coercion or any undue influence of others including healthcare providers. The Health Insurance Portability and Accountability Act (HIPAA) supports and upholds the clients’ rights to confidentially and the privacy of their medical related information regardless of its form. It covers hard copy and electronic medical records unless the client has formally approved the sharing of this information with others such as family members. The elements of informed consent which includes information about possible treatments and procedures in terms of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it may be part of these advanced directives, but the law that protects these advance directives is the Patient Self Determination Act. 3. Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The priority role of the nurse is advocacy. The nurse must serve as the advocate for both the fetus and the mother at risk as the result of this ethical dilemma where neither option is desirable. As an advocate, the nurse would seek out resources and people, such as the facility’s ethicist or the ethics committee, to resolve this ethical dilemma. 5. A nurse who organizes and establishes a political action committee (PAC) in their local community to address issues relating to the accessibility and affordability of healthcare resources in the community is serving in which capacity and role of the registered nurse? A. Client advocate B. Collaborator C. Politician D. Entrepreneur Correct Response: A A nurse who organizes and establishes a political action committee (PAC) in their local community to address issues relating to the accessibility and affordability of healthcare resources in the community is serving as the client advocate. As you should know, the definition of “client” includes not only individual clients, and families as a unit, but also populations such as the members of the local community. Although the nurse, as the organizer of this political action committee (PAC), will have to collaborate with members of the community to promote the accessibility and affordability of healthcare resources in the community, this is a secondary role rather than the primary role. Additionally, although the nurse is serving in a political advocacy effort, the nurse is not necessarily a politician and there is no evidence that this nurse is an entrepreneur. 6. Which of the following are the five Rights of Supervision? A. The right task, the right circumstances, the right person, the right competency, and the right supervision or feedback B. The right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback C. The right competency, the right education and training, the right scope of practice, the right environment and the right client condition D. The right competency, the right person, the right scope of practice, the right NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED environment and the right client condition NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: B The Five Rights of Delegation include the right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback. The right competency is not one of these basic Five Rights, but instead, competency is considered and validated as part of the combination of matching the right task and the right person; the right education and training are functions of the right task and the right person who is able to competently perform the task; the right scope of practice, the right environment and the right client condition are functions of the legal match of the person and the task; and the setting of care which is not a Right of Delegation and the matching of the right person, task and circumstances. 7. The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration? A. The American Nurses Association’s Scopes of Practice B. The American Nurses Association’s Standards of Care C. State statutes D. Federal law Correct Response: C The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on state statutes that differentiate among the different types of nurses and unlicensed assistive personnel that are legally able to perform different tasks. Although the American Nurses Association’s Standards of Care guide nursing practice, these standards are professional rather than legal standards and the American Nurses Association does not have American Nurses Association’s Scopes of Practice, only the states’ laws or statutes do. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Administration. He receives a substantial monthly service connected disability check from the Veterans Administration and he has no spouse or legal dependents. Which type of governmental health insurance is he now entitled to? A. Only the VA health care services because he is not 65 years of age B. Medicare because he has been deemed permanently disabled for 2 years C. Medicaid because he is permanently disabled and not able to work Choices B and C Correct Response: B This client is legally eligible for Medicare because he has been deemed permanently disabled for more than 2 years in addition to the VA health care services. People over the age of 65 and those who are permanently disabled for at least two years, according to the Social Security Administration, are eligible for Medicare. Based on the information in this scenario, the client is not eligible for Medicaid because has a “substantial” VA disability check on a monthly basis and is not indigent and with a low income. 11. You are a registered nurse who is performing the role of a case manager in your hospital. You have been asked to present a class to newly employed nurses about your role, your responsibilities and how they can collaborate with you as the case manager. Which of the following is a primary case management responsibility associated with reimbursement that you should you include in this class? A. The case manager’s role in terms of organization wide performance improvement activities B. The case manager’s role in terms complete, timely and accurate documentation C. The case manager’s role in terms of the clients’ being at the appropriate level of care D. The case manager’s role in terms of contesting denied reimbursements Correct Response: C Registered nurse case managers have a primary case management responsibility associated with reimbursement because they are responsible for insuring that the client is being cared for at the appropriate level of care along the continuum of care that is consistent with medical necessity NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED and the client’s current needs. A failure to insure the appropriate level of care jeopardizes reimbursement. For example, care in an acute care facility will not be reimbursed when the client’s current needs can be met in a subacute or long term care setting. Nurse case managers do not have organization wide performance improvement activities, the supervision of complete, timely and accurate documentation or challenging denied reimbursements in their role. These roles and responsibilities are typically assumed by quality assurance/performance improvement, supervisory staff and medical billers, respectively. 12. Select the nurse case management model used for patient care delivery that is accurately paired with one of its descriptors: A. The ProACT Model: Registered nurses perform the role of the primary nurse in addition to the related coding and billing functions B. The Collaborative Practice Model: The registered nurse performs the role of the primary nurse in addition to the role of the clinical case manager with administrative, supervisory and fiscal responsibilities C. The Case Manager Model: The management and coordination of care for clients throughout a facility who share the same DRG or medical diagnosis D. The Triad Model of Case Management: The joint collaboration of the social worker, the nursing case manager, and the utilization review team Correct Response: D The Triad Model of case management entails the joint collaboration of the social worker, the nursing case manager, and the utilization review team. The Professionally Advanced Care Team, referred to as the ProACT Model, which was developed at the Robert Wood Johnson University Hospital, entails registered nurses serving in the role of both the primary nurse the clinical case manager with no billing and coding responsibilities; these highly specialized and technical billing and coding responsibilities are done by the business office, medical billers and medical coders. The Case Manager Model entails the registered nurses’ role in terms of case management for a particular nursing care unit for a group of clients with the same medical diagnosis or DRG. In NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED contrast to this Case Manager Model of Beth Israel Hospital, the Collaborative Practice Model of case management entails the role of some registered nurses in a particular healthcare facility to manage, coordinate, guide and direct the complex care of a population of clients throughout the entire healthcare facility who share a particular diagnosis or Diagnostic Related Group. 13. Which of these case management methods employs the intrinsic use of multidisciplinary plans of care that are based on the client’s current condition, and reflect interventions and expected outcomes within a pre-established time line? A. The Case Manager Model B. The ProACT Model C. The Collaborative Practice Model D. The Triad Model of Case Management Correct Response: A The Case Manager Model and the Collaborative Practice Model of case management are the only models of case management that employ the mandated and intrinsic use of critical pathways which are multidisciplinary plans of care that are based on the client’s current condition, and that reflect interventions and expected outcomes within a pre-established time line. The ProACT Model, the Collaborative Practice Model and the Triad Model of Case Management do not necessarily employ critical pathways; these models can use any system of medical records and documentation. 14. Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization? A. An opt out consent B. An implicit consent C. An explicit consent D. No consent at all is given Correct Response: B NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED licensed healthcare professionals who assess, plan, implement and evaluate interventions including those related to the patient’s functional abilities in terms of their gait, strength, mobility, balance, coordination, and joint range of motion. They also provide patients with assistive aids like walkers and canes and exercise regimens. Occupational therapists assess, plan, implement and evaluate interventions including those that facilitate the patient’s ability to achieve their highest possible level of independence in terms of their activities of daily living such as bathing, grooming, eating and dressing. Podiatrists care for disorders and diseases of the foot; and nurse practitioners, depending on their area of specialty, may also collaborate with nurses when a client is affected with a disorder in terms of gait, strength, mobility, balance, coordination, and joint range of motion, however the member of the multidisciplinary team that you would most likely collaborate with when the client is at risk for falls due to an impaired gait is a physical therapist. 18. Select the member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for cutting food? A. The physical therapist B. The occupational therapist C. The dietician D. The podiatrist Correct Response: B The member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for eating is the occupational therapist. Occupational therapists assess, plan, implement and evaluate interventions including those that facilitate the patient’s ability to achieve their highest possible level of independence in terms of their activities of daily living such as bathing, grooming, eating and dressing. Many of these interventions include adaptive devices such as special eating utensils and grooming aids. Physical therapists are licensed healthcare professionals who assess, plan, implement and evaluate interventions including those related to the patient’s functional abilities in terms of their NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED gait, strength, mobility, balance, coordination, and joint range of motion. They also provide patients with assistive aids like walkers and canes and exercise regimens. Dieticians assess, plan, implement and evaluate interventions including those relating to dietary needs of those patients who need regular or therapeutic diets. They also provide dietary education and work with other members of the healthcare need when a client has dietary needs secondary to physical disorders such as dysphagia; and podiatrists care for disorders and diseases of the foot. 19. What is the primary goal of multidisciplinary case conferences? A. To fulfill the nurse’s role in terms of collaboration B. To plan and provide for optimal client outcomes C. To solve complex multidisciplinary patient care problems D. To provide educational experiences for experienced nurses Correct Response: C The primary goal of multidisciplinary case conferences is to plan care that facilitates optimal client outcomes. Other benefits of multidisciplinary case conferences include the fulfillment of the nurse’s role in terms of collaboration and collegiality, to solve complex multidisciplinary patient care problems so that optimal client outcomes can be achieved and also to provide educational experiences for nurses; these things are secondary rather than primary goals. 20. Which member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation one or more months ago? A. A Pedorthist B. A pediatric nurse practitioner C. A trauma certified clinical nurse specialist D. A prosthetist Correct Response: D The member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation secondary to a terrorism blast explosion a month NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED ago or more ago is a prosthetist. Prosthetists, in collaboration with other members of the healthcare team, assess patients and then design, fit and supply the patient with an artificial body part such as a leg or arm prosthesis. They also follow-up with patients who have gotten a prosthesis to check and adjust it in terms of proper fit, patient comfort and functioning. Pedorthists modify and provide corrective footwear and employ supportive devices to address conditions which affect the feet and lower limbs. Lastly, you may collaborate with a trauma certified clinical nurse specialist and a pediatric nurse practitioner but this consultation and collaboration should begin immediately upon arrival to the emergency department, and not a month after the injury. 21. Conflicts, according to Lewin, include which types of conflict? Select all that are accurate. A. Conceptualization conflicts B. Avoidance - Avoidance conflicts C. Approach - Approach conflicts D. Resolvable conflicts E. Unresolvable conflicts F. Double Approach - Avoidance conflicts G. Approach-Avoidance conflicts Correct Response: B, C, F, G According to Lewin, the types of conflict are Avoidance-Avoidance conflicts, Approach- Approach conflicts, Double Approach - Avoidance conflicts and Approach-Avoidance conflicts. 22. Select the types and stages of conflict that are accurately paired with their description. Select all that apply. A. Frustration: The phase of conflict that is characterized with personal agendas and obstruction B. Conceptualization: The phase of conflict that occurs when contending parties have developed a clear and objective understanding of the nature of the conflict and factors that have led to it C. Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict D. Resolution: The type of conflict that can be resolved NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The federal law is most closely associated with the highly restrictive “need to know” is the Health Insurance Portability and Accountability Act. This law restricts access to medical information to only those persons who have the need to know this information in order to provide direct and/or indirect care to the client. The Patient Self Determination Act, which was passed by the US Congress in 1990, gives Americans the right to make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so. These decisions can also include rejections for future care and treatment and these decisions are reflect in advance directives. This Act also supports the rights of the client to be free of any coercion or any undue influence of others including healthcare providers. The Mental Health Parity Act passed in 2008, mandates insurance coverage for mental health and psychiatric health services in a manner similar to medical and surgical insurance coverage. And, lastly the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 forbid and prohibit any discrimination against people with disabilities. 26. Which of the following personnel do not have the “right to know” medical information? A. The facility’s Performance Improvement Director who is not a healthcare person and who has no direct contact with clients B. A nursing student who is caring for a client under the supervision of the nursing instructor C. The facility’s Safety Officer who is not a healthcare person and who has no direct contact with clients D. A department supervisor with no direct or indirect care duties Correct Response: D A department supervisor with no direct or indirect care duties does not have the “right to know” medical information; all of the others have the “right to know” medical information because they provide direct or indirect care to clients. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED For example, both the facility’s Performance Improvement Director who is not a healthcare person and who has no direct contact with clients and the facility’s Safety Officer who is not a healthcare person and who has no direct contact with clients provide indirect care to clients. For example, they collect and analyze client data in order to fulfill their role and responsibilities in terms of process improvements and the prevention of incidents and accidents, respectively. Nursing and other healthcare students also have the “need to know” medical information so that they can provide direct client care to their assigned client(s). 27. You are the Nurse Manager for the trauma unit. Which of these staff comments or statements indicate the need for you to provide an educational activity relating to confidentiality and information security? A. “A computer in the hallway was left unattended and a client’s medical record was visible to me.” B. “I just saw a nursing student looking at the medical record for a client that they are NOT caring for during this clinical experience.” C. “As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians’ progress notes.” D. “I refused the nursing supervisor’s request to share my electronic password for the new nurse on the unit.” Correct Response: C A staff members comment, “As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians’ progress notes” “indicates the need for the Nurse Manager to provide an educational activity relating to confidentiality and information security because dieticians often have the “need to know” about laboratory data so that they can, for example, assess the client’s nutritional status in terms of their creatinine levels. The report that the nursing student was “looking at the medical record for a client that they are NOT caring for during this clinical experience” indicates that the reporting staff member is correctly applying the principles for maintaining confidentiality and privacy of information; the report that a “computer in the hallway was left unattended and a client’s medical record was NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED visible to me” indicates that the reporting staff member is correctly applying the principles for maintaining confidentiality and privacy of information; and lastly, “I refused the nursing supervisor’s request to share my electronic password for the new nurse on the unit” also indicates that the staff member is knowledgeable about privacy and confidentiality. 28. Which of the following terms is used to describe the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another? A. Case management B. Continuity of care C. Medical necessity D. Critical pathway Correct Response: B The continuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client’s status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client’s community. Case management and critical pathways may be used to facilitate the continuity of care, but they are not the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another. Lastly, medical necessity is necessary for reimbursement and it is one of the considerations for moving the client from one level of acuity to another but medical necessity is not the continuity of care. 29. The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized “hand of” change of shift reporting. Which of the following is a standardized “hand off” change of shift reporting system that you may want to consider for implementation on your nursing care unit? A. The Four P's B. UBAR C. ISBAR D. MAUMAR NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED status NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED S: Situation: The patient’s diagnosis, complaint, plan of care and the patient's prioritized needs and S: Safety concerns: Physical, mental and social risks and concerns 31. Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others 3,4,2,1,5,6 3,4,5,1,2,6 2,3,5,1,4,6 3,2,4,1,5,6 Correct Response: Client needs are prioritized in a number of different ways including Maslow’s Hierarchy of Human Needs and the ABCs. In terms of priorities from # 1 to # 6 the conditions above are prioritized as follows: An obstructed airway First degree heart block Atrial fibrillation Shortness of breath upon exertion Fluid needs Respect and esteem by others The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order; and Maslow’s Hierarchy of Needs identifies the NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self- actualization needs in that order of priority. 32. The 2nd priority needs according to the MAAUAR method of priority setting include which of the following? A. Assessment B. Movement C. Understanding level D. Risks Correct Response: D One of the 2nd priority needs according to the MAAUAR method of priority setting is risks. The ABCs / MAAUAR method of priority setting places the ABCs, again, as the highest and greatest priorities which are then followed with the 2nd and 3rd priority level needs of the MAAUAR method of priority setting. The 2nd priority needs according to the MAAUAR method of priority setting after the ABCs include M-A-A-U-A-R which stands for: Mental status changes and alterations Acute pain Acute urinary elimination concerns Unaddressed and untreated problems that require immediate priority attention Abnormal laboratory and other diagnostic data that are outside of normal limits and Risks including those relating to a healthcare problem like safety, skin breakdown, infection and other medical conditions NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: C Fully answering the client’s questions without any withholding of information is an example of the application of veracity into nursing practice. Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress. Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients. Beneficence is doing good and the right thing for the patient; it is nonmaleficence that is doing no harm. 37. You have been asked to teach an inservice class for nurses in your facility about ethics. Which of the following should you consider during the planning of this educational activity? A. Planning a way to evaluate the effectiveness of the class by seeing a decrease in the amount of referrals to the facility’s Ethics Committee B. Establishing educational objectives for the class that reflect the methods and methodology that you will use to present the class content C. The need to exclude case studies from the class because this would violate client privacy and confidentiality D. Some of the most commonly occurring bioethical concerns including genetic engineering into the course content Correct Response: D You would consider including some of the most commonly occurring bioethical concerns including genetic engineering into the course content. You would also plan how you could evaluate the effectiveness of the class by seeing an increase, not a decrease in the amount of referrals to the facility’s Ethics Committee, because one of the elements of this class should address ethical dilemmas and the role of the Ethics Committee in terms of resolving these. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED You would additionally establish educational objectives for the class that reflect specific, measurable learner outcomes and not the methods and methodology that you will use to present the class content; and lastly, there is no need to exclude case studies from the class because “sanitized” medical records can, and should be, used to avoid any violations of client privacy and confidentiality. 38. One of the roles of the registered nurse in terms of informed consent is to: A. Serve as the witness to the client’s signature on an informed consent. B. Get and witness the client’s signature on an informed consent. C. Get and witness the durable power of attorney for health care decisions’ signature on an informed consent. D. None of the above Correct Response: A One of the roles of the registered nurse in terms of informed consent is to serve as the witness to the client’s signature on an informed consent. Other roles and responsibilities of the registered nurse in terms of informed consent include identifying the appropriate person to provide informed consent for client, such as the client, parent or legal guardian, to provide written materials in client’s spoken language, when possible, to know and apply the components of informed consent, and to also verify that the client comprehends and consents to care and procedures. The registered nurse does not get the client’s or durable power of attorney for health care decisions’ signature on an informed consent, this is the role and responsibility of the physician or another licensed independent practitioner. 39. Which of the following is most closely aligned with the principles and concepts of informed consent? A. Justice B. Fidelity C. Self determination NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED D. Nonmalficence Correct Response: C Self-determination is most closely aligned with the principles and concepts of informed consent. Self-determination supports the client’s right to choose and reject treatments and procedures after they have been informed and fully knowledgeable about the treatment or procedure. Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients; fidelity is the ethical principle that requires nurses to be honest, faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner; and, lastly, nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. 40. Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent? A. The purpose of the proposed treatment or procedure B. The expected outcomes of the proposed treatment or procedure C. Who will perform the treatment or procedure D. When the procedure or treatment will be done Correct Response: D The minimal essential components of the education that occurs prior to getting an informed consent include the purpose of the proposed treatment or procedure, the expected outcomes of the proposed treatment or procedure, and who will perform the treatment or procedure. It is not necessary to include when the treatment or procedure will be done at this time. Other essential elements include: The benefits of the proposed treatment or procedure The possible risks associated with the proposed treatment or procedure NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Violated the client’s right to dignity Committed a crime Correct Response: D When you loosely apply a bed sheet around your client’s waist to prevent a fall from the chair, you have falsely imprisoned the client with this make shift restraint. False imprisonment is restraining, detaining and/or restricting a person’s freedom of movement. Using a restraint without an order is considered false imprisonment even when it is done to protect the client’s safety. Respondeat Superior is the legal doctrine or principle that states that employers are legally responsible for the acts and behaviors of its employees. Respondeat Superior does not, however, relieve the nurse of legal responsibility and accountability for their actions. They remain liable. There is no evidence in this question that you have violated the client’s right to dignity. 45. Which statement about Respondeat Superior is accurate? Respondeat Superior does not mean that a nurse cannot be held liable. Respondeat Superior does not mean that a nurse cannot be held libel. Respondeat Superior is an ethical principle. Respondeat Superior is a law. Correct Response: A Respondeat Superior does not mean that a nurse cannot be held liable and not libel which is a written defamation of character using false statements. Liability is legal vulnerability. Respondeat Superior is the legal doctrine or principle and not a law or ethical principle. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED 46. Which of these choices contains the six elements necessary for malpractice? Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct rather than indirect harm to the client. Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client. Causation, correlation, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client. Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and a medical license. Correct Response: B The six essential components of malpractice include causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and, lastly, this breach of duty led to direct and/or indirect harm to the client. A medical license is not necessary; nurses and other healthcare professionals can be found guilty of malpractice. Lastly, correlation is the relationship of simultaneously changing variables. For example, a ppositive correlation exists when the two variables both increase or decrease; and a negative occurs when one variable increases and the other decreases. 47. The current focus of performance improvement activities is to facilitate and address: Sound structures like policies and procedures Processes and how they are being done Optimal client outcomes Optimal staff performance Correct Response: C NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The current focus of performance improvement activities is to facilitate and address optimal client outcomes. Throughout the last several decades performance improvement activities have evolved from a focus on structures to a focus on process and now, to a focus on outcomes. Staff performance is not the focus of performance improvement activities but instead the focus of competency assessment and validation. 48. What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm? An adverse event A root cause A healthcare acquired event A sentinel event Correct Response: D A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future. An adverse event, like an adverse effect of a medication, has actually led to an adverse response; it is not a near miss. A root cause is a factor that has led to a sentinel event; and there is no such thing as a healthcare acquired event. 49. The primary purpose of root cause analysis is to: Discover a process flaw Determine who erred Discover environmental hazards Determine basic client needs NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The sensitizing dose of penicillin can lead to anaphylaxis. The second dose of penicillin can lead to distributive shock. You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex. You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex. Correct Response: B The second dose of penicillin can lead to anaphylactic shock which is a form of distributive shock. The first exposure to penicillin, referred to as the “sensitizing dose”, sensitizes and prepares the body to respond to a second exposure or dose. It is then the second exposure or dose that leads to anaphylaxis, or anaphylactic shock. It is estimated that approximately 10% of people have had a reaction to penicillin. Some of these reactions are an allergic response and others are simply a troublesome side effect. There is no scientific data that indicates that 10% or 20% of the population has an allergy to both penicillin and latex. 2. Which of these clients is at greatest risk for falls? A 77 year old female client in a client room that has low glare floors. An 87 year old female client in a client room that has low glare floors. A 27 year old sedated male client. A 37 year old male client with impaired renal perfusion. Correct Response: C The 27 year old sedated male client is at greatest risk for falls. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Some of the risk factors associated with falls are sedating medications, high glare, not low glare, floors and other environmental factors such as clutter and scatter rugs, not low glare floors, a history of prior falls, a fear of falling, incontinence, confusion, sensory deficits, a decreased level of consciousness, impaired reaction time, advancing age, poor muscular strength, balance, coordination, gait and range of motion and some physical disorders, particularly those that affect the musculoskeletal or neurological systems; falls are not associated with poor and impaired renal perfusion. 3. Which statement about environmental safety is accurate? The nurse should advise clients in a smoke filled room to open the windows. The first thing that the nurse should do when using a fire extinguisher to put out a small fire is to aim the fire extinguisher at the base of the fire. Rapidly lift and move a client away from the source of the fire when their slippers are on fire. The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher. Correct Response: D The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher because this one fire extinguisher is a combination of a type A fire extinguisher, a type B and a type C, which put out all types of fires including common household solids like wood, household oils like kitchen grease and electrical fires. The nurse should advise the client GET LOW AND GO if a room fills with smoke. They should not take any time to open window. The first thing to do when using a fire extinguisher is to pull the pin and then aim it at the base of the fire. Later, you would squeeze the trigger and sweep the spray over and over again over the base of the fire. The acronym PASS is used to remember these sequential steps. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED When a person has clothing that has caught on fire, the person should STOP, DROP AND ROLL. Tell the person, to STOP, DROP, and to not run, and as you also cover the person with a blanket to smother the fire. 4. Which of the following is considered an internal disaster? A tornado that has touched down on the healthcare facility A severe cyclone that has destroyed nearby homes A massive train accident that brings victims to your facility An act of bioterrorism in a nearby factory Correct Response: A A tornado that has touched down on the healthcare facility is an example of an internal disaster because this tornado has directly affected the healthcare facility. Tornados, cyclones, hurricanes and other severe weather emergencies can be both an internal disaster when they affect the healthcare facility and also an external disaster when they impact on the lives of those living in the community. Hurricane Katrina is a good example of a weather emergency that affected not only healthcare facilities but also members of the community. 5. After your assessment of your client and the need to transfer your client from the bed to the chair, what is the best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client’s first transfer out of bed? Use a slide board. Use a mechanical lift. Use a gait belt. Notify the client's doctor that the client cannot be safely transferred by you. Correct Response: B NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED It is damaging to the spleen and the liver. It leads to the over production of hemoglobin. Correct Response: A Carbon monoxide is particularly dangerous because it is clear, invisible and odorless. Carbon monoxide poisoning can occur when a person is exposed to an excessive amount of this odorless and colorless gas; it severely impairs the body to absorb life sustaining oxygen which is the result of this deadly gas and not damage to the lungs. This oxygen absorption deficit can lead to serious tissue damage and death. For these reasons, home carbon monoxide alarms are recommended. These dangers are associated with deoxygenation and not splenic or hepatic damage or the over production of hemoglobin. 9. The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a (n): Sentinel event. System variance. Adverse effect. Provider variance. Correct Response: B The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a system variance. A variance is defined as a deviation that leads to a quality defect or problem. Variances can be classified as a practitioner variance, a system/institutional variance, a patient variance, a random variance and a specific variance. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED A sentinel event is defined as is an event or occurrence, incident or accident that has led to or may possibly lead to client harm. Adverse effects are serious and unanticipated responses to interventions and treatments, including things like medications. 10. The first thing that you should do immediately after a client accident is to: Notify the doctor. Render care. Assess the cleint. Notify the nurse manager. Correct Response: C The first thing that you should do immediately after a client accident is to assess the client and the second thing you should do is render care after this assessment and not before it. Lastly, notifications to the doctor and the nurse manager are only done after the client is assessed and emergency care, if any, is rendered. 11. You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do? Counsel the staff about their need to stop wasting the resources of this department. Check the equipment yourself to determine the accuracy of this equipment department. Ignore it because everyone can make an innocent mistake. Plan an educational activity about determining what equipment to send for repairs. Correct Response: D NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED You should plan an educational activity about determining what equipment should and should not be sent for repairs. This data suggests that the staff members need education and training about the proper functioning of equipment used on the nursing care unit. Counseling the staff about their need to stop wasting the resources of this department is placing blame and this blame may prevent future valid returns of equipment. You should not check the equipment yourself to determine the accuracy of this equipment department because they are the experts, not you, with these matters. You should also not ignore it because everyone can make an innocent mistake. The issue has to be addressed and corrected. 12. Which of the following is an essential component for insuring that medical equipment is being used safely and properly by those who you supervise? Education and training on all pieces of equipment Pilot testing new equipment Reading all the manufacturer’s instructions Researching the equipment before recommending its purchase Correct Response: A Education and training on all pieces of equipment is an essential component for insuring that medical equipment is being used safely and properly by those who you supervise. Other essential components include validated and documented competency to use any and all pieces of equipment by a person qualified to do so, preventive maintenance and the prompt removal of all unsafe equipment from service. Pilot testing new equipment, researching the equipment before recommending its purchase, and reading the entire manufacturer’s instructions are things done prior to the purchase of the equipment and these things do not impact on the safety of the piece of medical equipment. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED the client should don a mask to prevent contamination. Lastly, a one inch border, not a ½ border that is not sterile is maintained around the perimeter of the sterile field. 16. Select the term which is most completely and accurately paired with its definition. A physical restraint: A physical restraint is a manufactured device that is used, when necessary, to prevent falls. A physical restraint: A physical restraint is any mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body. A chemical restraint: A chemical restraint is a drug used for sedation to prevent falls. A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms. Correct Response: D A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms, according to the Centers for Medicare and Medicaid Services. The most complete and accurate definition of a physical restraint is any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body and is NOT a safety devices that is routinely used for certain procedures, according to the Centers for Medicare and Medicaid Services. 17. Which of the following is NOT an essential component of a restraint order? Informed consent for the restraint The reason for the restraint The type of restraint to be used Client behaviors that necessitated the restraints NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: A The minimal components of orders for restraint include the reason for and rationale for the use of the restraint, the type of restraint to be used, how long the restraint can be used, the client behaviors that necessitated the use of the restraints, and any special instructions beyond and above those required by the facility’s policies and procedures. Informed consent is not necessary for the initiation or the use of restraints 18. Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. The vascular phase The prodromal phase The incubation phase The initial injury The exudate phase The convalescence phase 4,2,1 4,1,5 4,5,1 4,2,5 Correct Response: B The stages of the inflammatory process in correct sequential order are: The initial tissue injury which can result from an infection or a traumatic cause NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The vascular response. The release of histamine, prostaglandins and kinins. These substances lead to vasodilation which increases the necessary blood supply to the injured tissue and the area surrounding The exudate response. The release of leukocytes, including macrophages and neutrophils, to the injured area to combat the infection. The signs of infection such as the incubation, prodromal and convalescence stages, in the correct sequential order are: The incubation period The prodromal phase The illness stage The convalescence stage Health Promotion & Maintenance Practice Questions 1. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age? The infant had doubled their birth weight at twelve months. The infant had tripled their birth weight at twelve months. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight. The infant had grown ¼ inch since last month. Correct Response: A The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother’s reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Cross Linking Theory: This theory of aging explains that aging results for cell damage and disease from cross linked proteins in the body. Free Radicals Theory: This theory is based on the belief that free radicals in the body lead to cellular damage and the eventual cessation of organ functioning. Somatic DNA Damage Theory: Somatic DNA Damage theory is based on the belief that aging and death eventually occur because DNA damage, as continuously occurs in the human cells, continues to the point where they can no longer be repaired and replaced and, as a result, they accumulate in the body. 3. You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n): Increased creatinine clearance. Impaired immune system. Decreased hepatic metabolism. Increased bodily fat. Correct Response: C The elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a decrease in terms of their hepatic metabolism secondary to the hepatic functioning changes of the elderly secondary to a decreased hepatic blood flow and functioning. The elderly have decreased rather than increased creatinine clearance; the immune system is also decreased in terms of its functioning, however, this change impacts on the elderly’s ability to resist infection rather than impacting a medication’s side effects, adverse drug reactions, toxicity and over dosages; and, lastly, a decrease in terms of bodily fat, rather than an increase in terms of bodily fat impacts on medications. The distribution of drugs is impaired by decreases in the amount of body water, body fat and serum albumin; drug absorption is decreased with the aged patient’s increases in gastric acid pH and decreases in the surface area of the small intestine which absorbs medications and food nutrients. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED 4. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016? 7/7/2017 8/7/2017 6/7/2017 8/1/2017 Correct Response: A The expected date of delivery is calculated using Nagle’s rule which is: The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery For example, when the first day of the last menstrual period is 10/20/2016 you would: Subtract three months from 10/20/2016 and then you get 7/20/2016 and then Add seven days to 7/20/2016 and then get 7/27/2016, after which you would Add one year to 7/27/2016 to get the estimated date of delivery for7/27 of the following year which is 7/27/2017. 5. As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother? You should explain that fetal lie is where the fetus’ presenting part is within the birth canal during labor, among other information about the other assessments. You should explain that fetal presentation is the relationship of the fetus’s spine to the mother’s spine, among other information about the other assessments. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED You should explain that fetal attitude is the relationship of the fetus’ presenting part to the anterior, posterior, right or left side of the mother’s pelvis, among other information about the other assessments. You should explain that fetal station is the level of the fetus’ presenting part in relationship to the mother’s ischial spines, among other information about the other assessments. Correct Response: D You should explain that fetal station is the level of the fetus’ presenting part in relationship to the mother’s ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother’s ischial spines. Fetal station is -1 to -5 when the fetus is from 1 to 5 centimeters above the ischial spines and it is from +1 to +5 when the fetus is from 1 to 5 centimeters below the level of the maternal ischial spines. Fetal lie is defined as the relationship of the fetus’s spine to the mother’s spine. Fetal lie can a longitudinal, transverse or oblique life. Longitudinal lie, the most common and normal lie, occurs when the fetus’ spine is aligned with the mother’s spine in an up and down manner; a transverse lie occurs when the fetus’ spine is at a right ninety degree angle with the maternal spine; and, lastly, an oblique lie occurs when the fetus’ spine is diagonal to the mother’s spine. Fetal presentation is defined by where the fetus’ presenting part is within the birth canal during labor. The possible fetal presentations are the cephalic presentation, the cephalic vertex presentation, the cephalic sinciput presentation, the cephalic face presentation, the cephalic brow presentation, the breech presentation, the complete breech presentation, the frank breech presentation, the shoulder breech presentation, and the footling presentation. Fetal attitude is the positioning of the fetus’s body parts in relationship to each other. The normal attitude is general flexion in the “fetal position”. All attitudes, other than the normal attitude, can lead to a more intense and prolonged labor. Fetal position is the relationship of the fetus’ presenting part to the anterior, posterior, right or left side of the mother’s pelvis. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED 7. You are working in a community pediatric health clinic. Which expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages? Pregnancy Puberty Childhood immunizations Separation anxiety Correct Response: B The expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages is puberty. Throughout the life span, there are several significant expected life transitions that require the person to cope and adjust. Some of these expected life transitions include puberty, maternal and paternal attachments and bonding to the neonate, pregnancy, care of the newborn, parenting, and retirement. Although young children will experience separation anxiety and they will also be maintained on an immunization schedule, these are not expected life changes. 8. Registered nurses care for clients in many settings and environments. These clients can be individual clients, couples, families, populations and communities. You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model? The Biophysical Dimension The Psychological and Emotional Dimension The Spiritual Dimension The Health Systems Dimension NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: C The Dimensions Model of Health includes six dimensions that impact on the client, including the community. The Spiritual Dimension is not one of these six dimensions. These dimensions are the: Biophysical Dimension Psychological and Emotional Dimension Health Systems Dimension Behavioral Dimension Socio-Cultural Dimension Physical Environment Dimension 9. You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of: Mediterranean ethnicity for cystic fibrosis. African American ethnicity for Tay Sachs disease. British Isles ethnicity for psychiatric mental health disorders. Saudi Arabian ethnicity for sickle cell anemia. Correct Response: D You would identify a client who is of Saudi Arabian ethnicity for sickle cell anemia. Other ethnicities at greatest risk for sickle cell anemia include those who are African, Latin Americans, Southern Europeans and some clients from some Mediterranean nations. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Other disorders and diseases and the ethnicities associated with them are listed below Thalassemia: Clients with a Mediterranean ethnicity Tay Sachs Disease: Ashkenazi Jewish people Cystic Fibrosis: Clients with a European ethnicity Psychiatric Mental Health Disorders: African Americans and Native Americans Hypertension: African Americans, Pacific Islanders , Native Americans, Alaskan natives, Hispanic and Caribbean clients Diabetes: African Americans, Caribbeans, Native Americans and clients from India, Pakistan and Bangladesh Cancer: Caucasians and clients from Scotland and Ireland 10. Which statement about targeted assessments is accurate? The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms. The need for a targeted assessment is based on the application of the nurse’s knowledge of developmental needs and developmental delays. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients. Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment. Correct Response: A The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms. Targeted assessments and screenings are done in addition to routine and recommended screenings when a particular disorder has a genetic pathophysiological component for risk and when a client is presenting with a particular sign or symptom. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED 13. Your 87 year old client has a history of heart disease and fibromyalgia. This client has an internal pacemaker and is also a diabetic client. During your annual visit with this client, the client tells you that they would like to begin some alternative and homeopathic health care practices. What should you include in your teaching plan for this client? Information about the lack of scientific evidence regarding the effectiveness of all herbs. Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client. Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client. Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client’s pacemaker functioning. Correct Response: C Scientific data now indicates that prayer is effective for the relief of stress, anxiety and pain, and as such, may be helpful to this client. Some herbs, minerals and supplements are scientifically deemed as safe and effective and others are not scientifically effective and they can also lead to harm; at the current time, the National Institutes of Health (NIH) states that magnets are not scientifically effective and they are also not considered safe for clients with a pacemaker or insulin pump because these internally implanted devices can be adversely affected by the magnetic force of the magnet; and, lastly, biofeedback does not interfere with the client’s pacemaker functioning. 14. You assess your family as having a deficit in terms of their instrumental activities of daily living (ADLs). Which healthcare professional would you most likely refer this family to in order to address this deficit? A social worker A physical therapist An occupational therapist A speech therapist NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: A The healthcare professional would you most likely refer this family to in order to address this deficit in terms of their instrumental activities of daily living (ADLs) is a social worker. The activities of daily living are differentiated in terms of the basic activities of daily living and the instrumental activities of daily living. Examples of basic activities of daily living include things like bathing, mobility, ambulation, toileting, personal care and hygiene, grooming, dressing, and eating. Deficits in terms of the basic activities of daily living are best addressed by a physical and/or occupational therapist. The instrumental activities of daily living are more advanced than the basic activities of daily living. The instrumental activities of daily living include things like grocery shopping, housework, meal preparation, the communication with others using something like a telephone, and having transportation. Deficits in terms of the instrumental activities of daily living are best addressed by a social worker. For example, the social worker may assist the client in terms of their transportation and they can also teach the client about how to grocery shop, for example. 15. Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply. Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain. Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity. Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes. Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle. Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands Correct Response: A,B,D,E The olfactory cranial nerve is a sensory nerve that transmits the sense of smell to the olfactory foramina of the nose; the optic cranial nerve is also a sensory nerve and it transmits the sense of vision from the retina to the brain. The trochlear cranial nerve is a motor nerve that innervates eye ball movement and the superior oblique muscle of the eyes; and the abducens cranial nerve is a motor nerve that innervates and controls the abduction of the eye using the lateral rectus muscle. The oculomotor cranial nerve is a motor nerve controls eye movements, the sphincter of the pupils and the ciliary body muscles; it has no sensory function. The facial cranial nerve is a motor and sensory nerve which controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue. And, lastly, the glossopharyngeal cranial nerve is both a motor and sensory nerve that gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands. 16. The sense of hearing is assessed using which standardized test? The Taylor test The Rinne test The Babinski test The APGAR test Correct Response: B The sense of hearing is assessed using the Rinne test and the Weber test and a tuning fork. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Tympany: A hollow sound Dullness: A thud like sound Dullness: A hollow sound Resonance: A booming sound Correct Response: B Dullness is a thud like sound and not a hollow sound. Tympany is a drum like sound; and resonance is a hollow sound. Psychosocial Integrity Practice Questions 1. Which couple is at greatest risk for domestic violence? A couple which consists of a husband and wife both of whom are affected with Alzheimer’s disease A poverty stricken couple without any healthcare resources in the community A pregnant woman and a husband who was physically abused as a young child A wealthy couple with feelings that they are immune from punishment and above the law Correct Response: C A pregnant woman and a husband who was physically abused as a young child is the couple is at most risk for domestic violence because pregnancy and a personal prior history of abuse are two commonly occurring risk factors among abused woman and male abusers, respectively. Current research indicates that abuse and neglect affect all people of all ages and of all socioeconomic classes including the wealthy as well as the poverty stricken. Other patient populations at risk of abuse and neglect include female gender, infants, children, the cognitively impaired, the developmentally challenged, the elderly and those with physical or NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED mental disabilities; some of the other traits and characteristics associated with abusers include NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED substance related use and abuse, a psychiatric mental health disorder, poor parenting skills, poor anger management skills, poor self-esteem, poor coping skills, poor impulse control, immaturity, and the presence of a current crisis. 2. You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client’s past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others? Restrain the client Place the client in seclusion Get an order for a sedating medication Establish trust with the client. Correct Response: D The first thing that you should do to prevent violence towards others is to establish trust with the client. The first step in the nurse-client relationship is to establish trust in this therapeutic relationship. Without trust future collaboration, interventions and client outcomes cannot be accomplished to facilitate appropriate and safe behaviors. Restraints and seclusion are not indicated until others are in imminent danger because of this client’s current violent behaviors and not a history of it. Lastly, sedating medications to prevent violence are also not the first things that are done. 3. You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they “suffer and feel lousy” when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client? Psychological dependence secondary to amphetamine use Substance abuse secondary to amphetamine use Addiction secondary to amphetamine use Physical dependence secondary to amphetamine use NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: D The characteristics of the stages or phases of crisis, in the correct sequential order, are: Level 1 Crisis Signs and Symptoms: Patients experiencing a level one crisis typically experience anxiety and they also typically begin to use one or more psychological ego defense mechanisms. Level 2 Crisis Signs and Symptoms: Patients experiencing a level two crisis most likely exhibit some loss of their ability to function. They may also try to experiment with alternative methods of coping in order to deal with the crisis that is not being effectively coped with using one’s currently used coping mechanisms. Level 3 Crisis Signs and Symptoms: Patients experiencing a level three crisis show the signs and symptoms of the General Adaptation Syndrome which is characterized with fight, flight and panic as discussed above under the section entitled “Coping Mechanisms: Introduction”. Level 4 Crisis Signs and Symptoms: Clients experiencing a level four crisis exhibit severe signs and symptoms such as being totally detached and removed from others, feeling overwhelmed, becoming disoriented, and even with thoughts of violence toward self and others. 6. Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using? Displacement Sublimation Dissociation Reaction formation Correct Response: C Dissociation is the psychological ego defense mechanism occurs when the client detaches and dissociates with person or time to avoid the stress until they are ready to cope with it. Displacement transforms the target of one’s anger and hostility from one person to another person or object. Displacement allows the person to ventilate and act out on their anger in a less harmful and a more socially acceptable manner. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED A client uses the ego defense mechanism of sublimation when they transform and replace unacceptable urges and feelings into a socially acceptable urge or feeling. A client is using reaction formation when the client acts and behaves in a manner that is completely the polar opposite of their true feelings. 7. You are the Assistant Director of Nursing in a multiethnical and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing mutiethnicity and the culturally diverse nature of this facility for this philosophy? Jean Watson's Martha Rogers' Nagi's theory Madeleine Leininger’s theory Correct Response: D The theoretical framework that you would recommend that this committee should consider when addressing mutiethnicity and the culturally diverse nature of this facility for this philosophy is Madeleine Leininger’s theory. Madeleine Leininger’s theory of Transcultural Nursing and her book “Culture Care Diversity and Universality: A Theory of Nursing” “searches for comprehensive and holistic care data relying on social structure, worldview, and multiple factors in a culture in order to get a holistic knowledge base about care” (Leininger, 2006, p. 219) Jean Watson’s Jean Watson developed the Human Caring Theory which states that caring is the essence of nursing. Watson's theory has the four major concepts of health, nursing, NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED society/environment and human being. Caring consists of the following 10 nursing interventions that demonstrate genuine caring. Martha Rogers’ theory is the Science of Unitary Human Beings which is based on general systems theory without any focus on multiethnicity and cultural diversity; and lastly, Nagi’s Model of disability model describes disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives. 8. You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients? The client will accept impending death Guilt related to past transgressions Spiritual distress related to guilt Pain related to end of life symptoms Correct Response: A “The client will accept impending death” is the client goal would be the most likely appropriate and expected for the vast majority of these clients. In fact, one of the primary goals of hospice and palliative care is to facilitate the client’s and family member’s acceptance. Other goals are the freedom for guilt, spiritual distress and pain at the end of life; therefore, these diagnoses are not expected. 9. You are caring for a hospice client who is at the end of life. Based on this client’s signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client? NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED lost person, and, finally, resuming one’s life while still having a healthy connection with the loved one. Engel’s Stages of Grieving include stages both prior to and after a loss and these stages are: Shock and disbelief Developing awareness Restitution Resolving the loss Idealization Outcome Kubler Ross’s Stages of Grieving occur prior to the death and these stages include: Denial Anger Bargaining Depression Acceptance Lastly, Lewin developed theories of change, leadership and conflict and NOT a theory related to grief after the loss of a loved one. 12. As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients? The concern related to the client’s cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders Concerns revolving around the lack of financial and health insurance resources to pay for psychological care NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Concerns related to the compliance with psychological treatment regimens because of the client’s lack of social support systems The concern related to the culturally based client apathy about nursing care and nursing assessments Correct Response: A The concern related to the client’s cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders which is a barrier to assessment because the client fears being stigmatized and rejected when divulging psychological data including anxiety and other symptoms. The lack of financial and health insurance resources to pay for psychological care, the lack of social support systems, and the client’s apathy are barriers to psychological care but these factors are not a barrier to a psychological assessment and these factors are not cultural, but instead social and psychological. 13. You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients? Cognitive psychotherapy Behavioral psychotherapy Cognitive behavioral psychotherapy Psychoanalysis Correct Response: B Behavioral psychotherapy is particularly useful among clients who are adversely affected with phobias, substance related disorders, and other addictive disorders. Some of the techniques that are used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling and complementary and alternative stress management techniques. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Cognitive psychotherapy is most often used to treat clients, including groups of clients, with depression, eating disorders, anxiety, and anxiety disorders to facilitate the altering of the clients’ attitudes and perspectives relating to stressors. Cognitive behavioral psychotherapy, which is a combination of cognitive psychotherapy and behavioral psychotherapy and also referred to as dialectical behavioral therapy is most often used for clients affected with a personality disorder and those at risk for injury and harm to self and/or others. Psychoanalysis, in contrast to cognitive behavioral therapy and other individual and group therapies, dives into the client’s subconscious and it often focuses on the past as well as the client’s current issues. This therapy is not conducted by registered nurses but, instead, by experienced psychotherapists. 14. Select the client religion that is the most pertinent to the role of the admissions coordinator of hospital who assigns the rooms and beds of clients who will be admitted. Hinduism Buddhism Islam Mormonism Correct Response: C The client religion that is the most pertinent to the role of the admissions coordinator of hospital who assigns the rooms and beds of clients who will be admitted is the Islam religion which requires that the followers face Mecca for daily prayer, therefore, Islam clients should be placed in a room that faces the holy city of Mecca. Although most religions impact on the care of the client, only Islam is pertinent to the admissions coordinator. Other religions practices and their impact on health care are shown below: NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Collecting baseline blood pressure readings prior to the beginning of this educational series and then collecting and comparing blood pressure data after the series is completed gives us only summative evaluation; it does not provide you with formative evaluation. Because the primary goal of this series is to lower the blood pressures of clients through the use of stress management techniques, asking the clients how often they use the stress management techniques that they have learned during this educational series and using a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series does not reflect data and information about the effectiveness of the classes in terms of reducing the blood pressures of hypertensive clients. 17. Which of these stress management techniques employs deep focused breathing, movement and meditation? Reiki Tai Chi Feng Shui Jiu Jitsu Correct Response: A Tai Chi is a type of a mind body exercise that deeply focuses on breathing, movement and meditation. Yoga is similar to tai chi in that yoga also employs a combination of breathing, movement and meditation. Reiki is done for the client when the therapist places their hands on or near the person’s body to promote the client’s energy field and its own natural healing processes. Feng shui is an eastern method of decorating using colors, items and the placement of objects in the environment to promote a harmonious relationship of man and its environment; and lastly Jiu Jitsu is a martial art. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED 18. You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the couple and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer’s disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband? You should advise the couple to move closer to their children so that they can care for their father. You should teach the wife about this progressive disease and the need to promote as much independence as possible. You should teach the wife about this progressive disease and the need to do all that she can for the husband to avoid his depression and frustration. You should advise the couple to decrease their social activities in order to preserve the husband’s dignity and self-esteem. Correct Response: B You should teach the wife about this progressive disease and the need to promote as much independence as possible. Client’s with Alzheimer’s disease and other disabilities, including physical disabilities, should be coached and encouraged to be as independent as possible. Moving closer to the children may not be appropriate advice particularly if the children are unable or unwilling to care for their father. Lastly, you should advise the couple to continue their social activities and to only avoid those situations where the necessary compassion and understanding about the client and his condition are absent. 19. You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer’s disease. You are planning a session on the stages of Alzheimer’s disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session? According to the Global Deterioration Scale, clients in the first stage of Alzheimer’s disease tend to cover up their failing abilities NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED According to the Reisberg Scale, clients in the first stage of Alzheimer’s disease tend to cover up their failing abilities According to the Global Deterioration Scale, clients in the third stage of Alzheimer’s disease tend to cover up their failing abilities According to the Reisberg Scale, clients in the fourth stage of Alzheimer’s disease tend to cover up their failing abilities Correct Response: C According to the Global Deterioration Scale, also referred to as the Reisberg Scale, clients in the third stage of Alzheimer’s disease tend to cover up their failing abilities. The Global Deterioration Scale stages Alzheimer’s according to seven stages. These stages include Stage 1: Cognitive abilities are intact. Stage 2: Minimal and hardly noticeable forgetfulness occurs. Stage 3: Mild changes in terms of cognition occur. The client may have difficulty in terms of their memory, which at times the client may “cover up” to avoid the detection by others. The signs and symptoms of this stage are similar to those of the Early Stage of Alzheimer’s disease, as discussed immediately above. Stage 4: This stage is characterized with increasing confusion about recent events and conversations, mild problems with math and some rather routinized sequential tasks such as cooking. The client may withdraw from others and debate the fact that they are having some cognitive issues. Stage 5: Early Dementia occurs. Short and long term memory losses, a lack of orientation to place and time, poor judgment, and some of the client’s self care in terms of the activities of daily living become progressively more problematic. The client may need the assistance and supervision of others to promote the client’s highest possible level of independence in the performance of their basic activities of daily living. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED An aphasia aid and a word board are assistive devices to facilitate communication when the client is affected with a communication deficit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor fine motor coordination. 3. As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do? Place the client in a wheelchair to protect their safety in the clinic. Remove the cane from the client to protect their safety. Teach the client about the proper length of a cane. Have the client use a wheelchair rather than the cane. Correct Response: C You should teach the client about the proper length of a cane. The proper length of the cane should be the length that only permits the client’s elbow to be slightly flexed. Some canes like a wooden cane are not adjustable to the client’s height and others can be adjusted to meet the height needs of the client. You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment and, as such, you should teach the client about the proper length of a cane and help them to adjust the height of the cane if the client’s cane is a height adjustable one. 4. You are caring for a post-operative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client? A cleansing enema A retention enema A return-flow enema A laxative NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Correct Response: C The most likely intervention for this client, after getting a doctor’s order, is a return flow enema. Return-flow enemas, similar to a carminative enema, are used to relieve flatus and stimulate peristalsis which is frequently a problem after a client has received anesthesia. Cleansing enemas are used to relieve constipation; and a retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate. Finally, the data in this question does not indicate that the client is constipated and in need of a laxative. 5. Which of the following is a commonality that is shared in terms of both restraints and urinary catheters? Both can lead to infection. Both are invasive procedures. Both are considered sentinel. Both are the last resort. Correct Response: D The commonality that is shared in terms of both restraints and urinary catheters is that both are the last, not the first, treatment of choice. Both indwelling urinary catheters and restraints pose risks and complication; therefore, both of these interventions must be prevented with the use of preventive measures. Indwelling urinary catheters are invasive but restraints are not invasive; indwelling urinary catheters can lead to infection but restraints do not. Lastly, neither are sentinel. A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future. 6. Your incontinent client is incontinent of urine and stool. Which of the following products would you recommend for this client when cost is a major consideration in this decision? Any solid skin barrier A hydrocolloid solid skin barrier Hollister’s Flextend A skin sealant Correct Response: D You would recommend a skin sealant, including products like Bard’s Protective Barrier and Convatec’s Allkare, which are a fast drying polymer transparent film that can be applied relatively simply with a wipe or a spray. These products are easy to use and less expensive than solid skin barriers, including Hollister’s Flextend and others containing hydrocolloids. 7. You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about? A prolapsed stoma A vitamin B12 deficiency Nocturnal enuresis GI stone formation Correct Response: A Some of the complications associated with a colostomy include a prolapsed stoma, infection, dehiscence, an ischemic ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and parastomal hernias. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Secondary prevention healing Correct Response: A Secondary intention healing is the most likely type of wound healing for this client because of the risks associated with the deep infection associated with the ruptured appendix and the peritonitis. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. The resulting scar is more obvious than those scars that result from primary intention healing. Primary intention healing is facilitated with wounds without infection. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some traumatic wounds are healed with tertiary intention. Primary, secondary and tertiary prevention strategies are prevention, interventions and restorative or rehabilitation care and not methods of wound healing. 12. You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound? A barrier film An alginate dressing NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED Surgical laser debridement Autolytic debridement Correct Response: B The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three colors are: Red: Covering with a dressing such as a hydrocolloid film, turning and positioning the client and avoiding pressure, friction and shearing Yellow: Using an alginate dressing Black: Debridement, including surgical laser debridement, mechanical debridement, autolytic debridement, enzymatic debridement and sharp instrument debridement, of the area to remove the black necrotic eschar. 13. Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this “gate” to pain are low endorphins and anxiety and that some of the factors that close this “gate” to pain are decreased anxiety and fear? Moritz Schiff’s theory of pain The Intensive Theory of Pain Melzack and Wall’s theory of pain The Specificity Theory of Pain Correct Response: C Melzack and Wall’s Gate Control Theory of pain supports the belief that some of the factors that open this “gate” to pain are low endorphins and anxiety and that some of the factors that close this “gate” to pain are decreased anxiety and fear. The substantia gelatinosa is the “gate” that facilitates or blocks the transmission of pain. NURS NCLEX RN EXAM QUESTIONS WITH ANSWERS 2023/2024 SUCCESS ASSURED The Specificity Theory of Moritz Schiff described pain as a sensation that was different from all the other senses in that pain had its own specific nervous system pathways from the spinal cord that traveled to the brain; the Intensive Theory of pain is based on the belief that pain is an emotional state, rather than a sensory phenomenon; the Peripheral Pattern Theory of pain of Sinclair and Weddell describes pain as the result of an intense stimulus applied to the skin; and the Neuromatrix Theory of Pain supports the fact that pain is a dynamic and multidimensional process with physical, behavioral, perceptual, psychological and social responses and one that can only be described by the person who is experiencing it. 14. You routinely use the PQRST method to assess pain. The PQRST method consists of: Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers Correct Response: D Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers are the PQRSTs of the PQRST method of pain assessment. The severity of the pain, which can include a quantitative, numerical pain score from 1 to 10, for example, is the S of the PQRST method of pain assessment. 15. The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes: Assessment data, biochemical data, clinical data and dietary data Ancestral cultural data, biochemical data, clinical data and dietary data Anthropometric data, biological data, chemical data and dietary data