Nursing Process NCLEX Questions

Correct Answer: D

Rationale: Step 1: Multiple sclerosis (MS) is characterized by damage to the myelin sheath, not a build-up of myelin. Step 2: MS affects the nerves, not neurotransmitters related to muscle contraction (eliminates choice B). Step 3: MS does not damage receptor sites on muscles but affects nerve signal transmission (eliminates choice C). Step 4: The correct answer, D, explains that MS damages the insulation on nerve cells (myelin sheath), leading to slower nerve impulses to the muscles, causing weakness and coordination issues.

Correct Answer: B

Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure. A: The nurse taking the temperature in different positions is not directly related to assessing hypertension. C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension. D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.

Correct Answer: D

Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.

Correct Answer: A

Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.

Correct Answer: C

Rationale: The correct answer is C because jaundice is a common manifestation of sickle cell anemia due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for the characteristic yellow discoloration indicating jaundice. This assessment is specific to identifying jaundice, which is directly related to the disease process. Choice A is incorrect as it relates to assessing neurological function, not jaundice. Choice B is incorrect as joint swelling is not a typical sign of jaundice in sickle cell anemia. Choice D is incorrect as a urine specimen is not used to assess jaundice; skin and sclera inspection are more appropriate.