Nursing Process NCLEX Questions

Correct Answer: A

Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis. Explanation of other choices: B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect. C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location. D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,

Correct Answer: C

Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.

Correct Answer: C

Rationale: The correct answer is C: Helper T cells. Helper T cells play a crucial role in activating B cells by releasing cytokines that stimulate B cell proliferation and differentiation. They also help in the production of antibodies. Cytotoxic T cells (A) are involved in cell-mediated immunity, not humoral immunity. Suppressor T cells (B) regulate the immune response and do not directly assist in B cell activation. Neutrophils (D) are phagocytic cells involved in innate immunity, not in activating B cells in humoral immunity.

Correct Answer: A

Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.

Correct Answer: A

Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.