Free NCLEX-RN Practice Test Questions and Answers (2026) Practice Questions

A weight gain of 1 lb (approximately 0.45 kg) per day is excessive and unrealistic for lean body mass accretion. Such rapid weight gain is a significant indicator of fluid retention and potential fluid overload, which can strain the cardiovascular system. A safe and appropriate weight gain goal for a client on nutritional support is typically 0.5 to 2 lbs (0.23 to 0.9 kg) per week. This statement demonstrates a fundamental misunderstanding of the therapeutic goals and potential complications of enteral nutrition, indicating a clear need for further teaching by the nurse.

A. Reporting diarrhea that persists for more than 2-3 days is the correct action, as it can signify a significant complication requiring medical intervention to prevent dehydration and electrolyte imbalance.

C. Elevating the head of the bed to at least 30-45 degrees during and after feedings is a critical aspiration precaution that uses gravity to prevent reflux and aspiration pneumonia.

D. Opened enteral formula is a growth medium for bacteria; it should be refrigerated and discarded after 24 hours to prevent contamination and subsequent gastrointestinal infection.

1. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.

Regarding Correct Answer (B): Chapter 45, Nutrition, discusses monitoring patient outcomes. It emphasizes that weight gain should be gradual. A rapid daily gain suggests fluid retention, a complication to be reported (p. 1135, "Monitoring for Complications").

Regarding Incorrect Option (C): Chapter 45, Nutrition, explicitly states, "A major cause of complications is aspiration of formula into the tracheobronchial tree... To prevent aspiration, allow the head of the bed to be elevated to a minimum of 30 degrees, preferably 45 degrees" (p. 1133, "Aspiration of Formula").

Regarding Incorrect Option (D): Chapter 45, Nutrition, details safe administration practices, including that the "hang time" for formula in an open system at room temperature is typically 8 hours, and any unused, opened formula must be refrigerated and discarded after 24 hours (p. 1132, Box 45.11 "Procedural Guidelines: Administering Enteral Tube Feedings").

2. Bankhead, R., Boullata, J., Brantley, S., et al. (2009). Enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition, 33(2), 122-167. https://doi.org/10.1177/0148607108330314

Regarding Incorrect Option (A): Section 7, "Monitoring the Patient Receiving EN," recommends monitoring for gastrointestinal tolerance, including diarrhea. It notes that if diarrhea is severe or persistent, the cause should be investigated and managed (p. 147).

Regarding Incorrect Option (C): Section 6, "Administration," recommends, "To decrease the risk of aspiration, elevate the head of the bed (HOB) to 30°-45°" (p. 144).

Projection is an ego defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or motives to another person. In this scenario, the client has romantic and sexual feelings for her physician. To cope with these potentially unacceptable or overwhelming feelings, she unconsciously projects them onto the doctor, believing that he is the one in love with her. This distortion of reality protects her from acknowledging her own desires. This specific manifestation is also characteristic of an erotomanic delusion, which can be a symptom in clients with schizophrenia.

A. Displacement: This involves shifting feelings from an original, threatening source to a less threatening substitute. The client's feelings are still directed at the physician, not a different target.

C. Reaction formation: This is the process of behaving in a way that is the exact opposite of one's true, unacceptable feelings. The client is not acting opposite to her feelings.

D. Suppression: This is the conscious, intentional act of pushing unpleasant thoughts or feelings out of one's mind. The client's belief is a delusion, an unconscious process, not a conscious choice.

1. Townsend, M. C., & Morgan, K. I. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. In the chapter on "Mental Health and Mental Illness," projection is defined as "attributing feelings or impulses unacceptable to one’s self to another person" (Table 2-2, Ego Defense Mechanisms, p. 20).

2. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer. Chapter 4, Section 4.5, "Defense Mechanisms," describes projection as a defense in which what is emotionally unacceptable in the self is unconsciously rejected and attributed to others.

3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). The clinical picture described aligns with an erotomanic type delusion, defined as the delusion that another person is in love with the individual. This delusion often involves projection of the individual's own feelings (p. 90). https://doi.org/10.1176/appi.books.9780890425596

The nursing process is a systematic, five-step clinical decision-making framework: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Assessment is the foundational first step, which involves the systematic collection, organization, validation, and documentation of patient data (subjective and objective). This comprehensive data provides the basis for the second step, Diagnosis, where the nurse analyzes the assessment findings to identify patient problems and formulate a nursing diagnosis. Without a thorough assessment, an accurate and appropriate nursing diagnosis cannot be made.

A. Write goals and objectives: This is a component of the Planning phase, which occurs after a nursing diagnosis has been identified.

C. Plan interventions: This is also part of the Planning phase, which is based on the established nursing diagnosis and goals.

D. Perform evaluation: This is the final step of the nursing process, conducted after interventions have been implemented to assess goal achievement.

1. Toney-Butler, T. J., & Thayer, J. M. (2023). Nursing Process. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/. (See section: "Phases of the Nursing Process," Paragraph 1, which lists assessment as the first phase).

2. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of Nursing (10th ed.). Elsevier. Chapter 17, "Nursing Diagnosis," states, "The diagnostic process flows from the assessment process and includes decision-making steps" (p. 232).

3. National Council of State Boards of Nursing (NCSBN). (2022). 2023 NCLEX-RN® Test Plan. The framework of the nursing process (Assessment, Analysis/Diagnosis, Planning, Implementation, Evaluation) is integrated throughout the test plan as a fundamental concept for providing safe and effective nursing care. (See Section III, "Clinical Judgment/Nursing Process," p. 5).

Waterhouse-Friderichsen syndrome is a rare, fulminant, and often fatal complication most commonly associated with severe meningococcemia (Neisseria meningitidis infection). The syndrome is defined by massive, bilateral adrenal hemorrhage, which leads to acute adrenal insufficiency. This abrupt loss of adrenal function, particularly cortisol and aldosterone production, results in profound hypotension, shock, and disseminated intravascular coagulation (DIC). The hallmark of this condition is a rapid progression to peripheral circulatory collapse. While other listed options are potential complications of bacterial meningitis, they describe different pathophysiological processes.

B. Syndrome of inappropriate antidiuretic hormone (SIADH) is a distinct complication of meningitis causing fluid retention and hyponatremia, not adrenal hemorrhage or primary circulatory collapse.

C. Cerebral edema and hydrocephalus are direct central nervous system complications from inflammation and obstructed cerebrospinal fluid flow, not the systemic adrenal failure seen in Waterhouse-Friderichsen syndrome.

D. Auditory nerve damage is a common neurological sequela of meningitis due to inflammation affecting cranial nerves, but it is unrelated to the adrenal crisis defining this syndrome.

1. Stephens, D. S. (2018). Meningococcal Meningitis. In J. L. Jameson, A. S. Fauci, D. L. Kasper, S. L. Hauser, D. L. Longo, & J. Loscalzo (Eds.), Harrison's Principles of Internal Medicine (20th ed.). McGraw-Hill Education. Chapter 151, section "Fulminant Meningococcemia (Waterhouse-Friderichsen Syndrome)."

2. Sonino, N., & Sonino, E. (2023). Waterhouse-Friderichsen Syndrome. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560593/. (See "Introduction" and "Pathophysiology" sections).

3. Varon, J., & Chen, K. (2008). The "sound" of a frightful syndrome. The Journal of Emergency Medicine, 35(2), 205–206. https://doi.org/10.1016/j.jemermed.2007.07.043 (See Abstract and Case Report sections describing the progression to shock).

4. Johns Hopkins Medicine. (n.d.). Waterhouse-Friderichsen Syndrome. Health Library. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/waterhousefriderichsen-syndrome. (See "What are the symptoms..." section, which lists shock as a primary symptom).

The classic clinical presentation of placenta previa is sudden, painless, bright red vaginal bleeding in the second or third trimester. Upon abdominal examination, the uterus is typically soft, relaxed, and non-tender. This is because the bleeding originates from the separation of the placenta from the lower uterine segment, and the blood escapes vaginally without irritating the uterine muscle (myometrium). The absence of uterine tenderness and rigidity is a key diagnostic feature that helps differentiate placenta previa from abruptio placentae.

A. A rigid, boardlike abdomen: This is the hallmark sign of a moderate to severe abruptio placentae, where concealed bleeding irritates the myometrium, causing tetanic contractions.

B. Uterine atony: This refers to the failure of the uterus to contract effectively after delivery and is a primary cause of postpartum hemorrhage, not an antepartum finding.

D. Hypertonicity of the uterus: This finding, characterized by excessive uterine tone and contractions that do not fully relax, is characteristic of abruptio placentae.

1. Oyelese, Y., & Smulian, J. C. (2006). Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics & Gynecology, 107(4), 927–941. In the section "Clinical Presentation and Diagnosis," the article states, "The classic presentation of placenta previa is painless vaginal bleeding... The uterus is usually soft and nontender." (p. 929). https://doi.org/10.1097/01.AOG.0000207559.15715.98

2. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (Eds.). (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education. In Chapter 41, "Obstetrical Hemorrhage," the text differentiates the clinical findings, noting that with placenta previa, "uterine palpation does not typically elicit tenderness."

3. University of California, San Francisco (UCSF) School of Medicine. (n.d.). Obstetrics and Gynecology Clerkship: Third Trimester Bleeding. Course materials describe the physical exam for placenta previa as revealing a "soft, non-tender uterus," contrasting it with the "firm, tender uterus (often with contractions)" seen in placental abruption.

Thalassemia is a genetic blood disorder causing chronic anemia. The primary treatment for severe forms is frequent blood transfusions. A major, life-threatening complication of chronic transfusion therapy is iron overload (hemosiderosis), as the body cannot naturally excrete the excess iron from transfused red blood cells. This iron accumulates in and damages vital organs like the heart, liver, and endocrine glands. Therefore, it is critical for the patient and family to be educated on the signs and symptoms of iron overload (e.g., fatigue, joint pain, arrhythmias, abdominal pain) to ensure early detection and adherence to chelation therapy, which removes excess iron from the body.

A. Iron supplementation is contraindicated because it would exacerbate the iron overload that already results from hemolysis and frequent blood transfusions.

B. While cardiac complications can occur from iron overload, routine weekly blood pressure monitoring is not a primary, specific discharge instruction for thalassemia.

D. Patients are encouraged to participate in physical activity as tolerated to promote well-being; a blanket restriction on exercise is inappropriate.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's nursing care of infants and children (11th ed.). Elsevier. In Chapter 29, "The Child with Hematologic or Immunologic Dysfunction," the section on Thalassemia Major (Cooley Anemia) discusses the therapeutic management, stating, "A complication of the repeated transfusions is hemosiderosis... To prevent organ damage from iron overload, chelation therapy... is begun." This underscores the importance of managing and monitoring for iron overload.

2. National Heart, Lung, and Blood Institute (NHLBI). (2022, March 24). Thalassemia - Treatment. U.S. Department of Health & Human Services. In the section "Iron Chelation Therapy," it is stated, "Blood transfusions can lead to a buildup of iron in the blood (iron overload). This condition can damage the liver, heart, and other parts of the body... your doctor may prescribe iron chelation therapy to remove excess iron from your body." This highlights iron overload as a direct consequence of treatment requiring management and patient awareness.

3. Angelucci, E., & Barosi, G. (2013). Management of iron overload in thalassemia and other congenital anemias. In A. V. Hoffbrand & D. G. Higgs (Eds.), Postgraduate Haematology (7th ed., pp. 127-141). Wiley-Blackwell. Chapter 9 details the pathophysiology of transfusional iron overload and emphasizes patient education for adherence to chelation therapy as a cornerstone of management to prevent organ toxicity.

The therapeutic range for lithium is notoriously narrow, requiring close monitoring to maintain efficacy and prevent toxicity. For acute manic episodes, the target serum level is typically 1.0 to 1.5 mEq/L. For long-term maintenance therapy, the desired range is lower, generally between 0.6 and 1.2 mEq/L. The option 0.5–1.5 mEq/L correctly encompasses both the maintenance and acute therapeutic ranges. Levels below 0.5 mEq/L are generally subtherapeutic, while levels exceeding 1.5 mEq/L are associated with a significant increase in the risk of toxicity.

A. 0.25–1.0 mEq/L: The lower end of this range (0.25 mEq/L) is subtherapeutic and would likely be ineffective in managing bipolar disorder.

C. 1.0–2.0 mEq/L: Serum concentrations above 1.5 mEq/L are generally considered toxic. This range extends into dangerous levels that can cause serious adverse effects.

D. 2.0–2.5 mEq/L: This range represents severe lithium toxicity, which can lead to life-threatening complications such as seizures, coma, and cardiovascular collapse.

1. Hedya, S. A., & Avula, A. (2023). Lithium Toxicity. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499992/. (See "Pathophysiology" and "History and Physical" sections, which state therapeutic levels are 0.6 to 1.2 mEq/L, with toxicity beginning at 1.5 mEq/L).

2. University of Washington, Department of Psychiatry and Behavioral Sciences. (n.d.). AIMS Center Bipolar Disorder Medication Quick Reference Guide. Retrieved from https://aims.uw.edu/resource-library/bipolar-disorder-medication-quick-reference-guide/. (This guide specifies the therapeutic blood level for Lithium as 0.6-1.2 mEq/L).

3. Ghaemi, S. N. (2019). The evidence for and against the use of lithium in bipolar disorder. Acta Psychiatrica Scandinavica, 140(5), 394-396. https://doi.org/10.1111/acps.13096 (This article discusses standard therapeutic levels, noting the typical target range of 0.6-1.2 mmol/L, which is equivalent to mEq/L for lithium).

A pulse oximeter is a non-invasive device that measures the peripheral oxygen saturation of arterial blood (SpO2). It functions by emitting two wavelengths of light (red and infrared) through a translucent, pulsating vascular bed, such as a fingertip or earlobe. The device then measures the differential absorption of this light by oxygenated hemoglobin (oxyhemoglobin) and deoxygenated hemoglobin. By analyzing these differences in light absorption during arterial pulsations, the oximeter calculates the percentage of hemoglobin molecules that are saturated with oxygen, providing a continuous estimate of arterial oxygenation.

A. O2 content of the blood: This is incorrect because pulse oximetry does not measure the oxygen dissolved in plasma, only the saturation of available hemoglobin.

C. PO2: This is incorrect as it refers to the partial pressure of oxygen dissolved in the blood, a value measured directly through an arterial blood gas (ABG) analysis.

D. Affinity of hemoglobin for O2: This is incorrect as it describes the binding strength between oxygen and hemoglobin, which is influenced by factors like pH and temperature, not measured by oximetry.

1. Jubran, A. (2015). Pulse oximetry. Critical Care, 19(1), 272. In the "Principles of operation" section, paragraph 1, it states, "Pulse oximetry provides a noninvasive and continuous estimate of arterial oxygen saturation (SpO2)." https://doi.org/10.1186/s13054-015-0984-8

2. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier. In Chapter 30, "Oxygenation," under the section "Pulse Oximetry," it is specified that the device measures "the oxygen saturation of hemoglobin in arterial blood." (p. 579).

3. Johns Hopkins University. (n.d.). Arterial Blood Gas. Johns Hopkins Medicine, Health Library. This resource differentiates between measurements, stating, "A pulse oximeter only measures oxygen saturation... An ABG test measures oxygen saturation, but it also measures the partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2)." This clarifies why options B and C are distinct.

4. World Health Organization. (2011). Pulse oximetry training manual. WHO Press. In Module 1, "The Basics," Section 1.2, "What is pulse oximetry?", it is defined as "a non-invasive method used to measure the level of oxygen saturation in the blood." (p. 4).

The most immediate nursing intervention after a suspected rupture of membranes is to assess the fetal heart rate (FHR). This is the priority because of the risk of umbilical cord prolapse. When the membranes rupture, the umbilical cord can be washed down with the gush of fluid and become compressed between the fetal presenting part and the maternal pelvis. This compression obstructs blood flow and oxygen to the fetus, which is immediately reflected in the FHR as bradycardia or severe variable decelerations. Assessing the FHR is the fastest way to determine fetal well-being and identify this life-threatening emergency.

A. Noting the fluid is an important assessment but is secondary to evaluating fetal status. Fetal well-being is the highest priority.

C. The physician must be notified, but the nurse should first perform a critical assessment to provide accurate, up-to-date information, such as the FHR.

D. Confirming the rupture of membranes with a nitrazine test is appropriate but not the first priority. The immediate risk to the fetus must be assessed first.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity and Women's Health Care (12th ed.). Elsevier. In Chapter 16, "Labor and Birth Processes," under the section "Rupture of Membranes," the text states, "The first priority of care after the membranes rupture is to assess the FHR and pattern" (p. 381).

2. National Council of State Boards of Nursing (NCSBN). (2022). 2023 NCLEX-RN® Test Plan. This question aligns with the Client Needs Category "Reduction of Risk Potential," which requires the nurse to "identify acute, life-threatening complications" and "initiate immediate interventions." Assessing FHR post-ROM is a key intervention to mitigate the risk of fetal compromise (p. 21).

3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2021). Fetal Heart Monitoring Principles and Practices (6th ed.). Kendall Hunt Publishing. Chapter 4 discusses the evaluation of fetal well-being and emphasizes that events like rupture of membranes are critical points for FHR assessment to detect potential cord compression events.

The client is exhibiting splitting, a primitive defense mechanism commonly associated with borderline personality disorder. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive whole. The client's statement, "Nobody in here seems to really care... I thought nurses cared about people!" demonstrates this "all-or-nothing" thinking. She is devaluing the current nursing staff as "all bad" because they are not meeting her idealized expectation of what nurses should be ("all good"). This dichotomous thinking is the hallmark of splitting.

A. Reaction formation: This is expressing the opposite of one's true feelings. The client is expressing anger and hostility, which appear congruent with her internal state.

B. Rationalization: This involves creating logical-sounding excuses to justify unacceptable feelings or behaviors. The client is not making an excuse for her actions.

D. Sublimation: This is the channeling of unacceptable impulses into socially acceptable actions. The client's verbal hostility is not a socially constructive outlet.

1. Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer. In Chapter 18, "Personality Disorders," the text describes splitting as a primary defense mechanism used by clients with borderline personality disorder, characterized by the tendency to view others as either all good or all bad (p. 341).

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). In the section on Borderline Personality Disorder (301.83), the diagnostic criteria include "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation," which is the behavioral manifestation of splitting (p. 663).

3. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. This article discusses primitive defenses in BPD, defining splitting as "the segregation of contradictory experiences of the self and of significant others" (p. 1360). https://doi.org/10.1017/S095457940999009X

The standard procedure for modified electroconvulsive therapy (ECT) involves the administration of a specific sequence of medications to ensure patient safety and comfort. An anticholinergic agent, such as atropine, is given to decrease secretions and counteract vagal stimulation (bradycardia). A short-acting anesthetic, like methohexital (Sodium Brevital), is administered to induce unconsciousness. Finally, a neuromuscular blocking agent, such as succinylcholine chloride (Anectine), is used to produce muscle paralysis, preventing the motor component of the seizure and minimizing the risk of musculoskeletal injury. This combination is the established protocol for administering ECT.

A. Lithium is typically discontinued before ECT as it can increase the risk of neurotoxicity and prolong seizures. The other medications are not standard for the ECT procedure itself.

C. These are electrolytes. While their balance is important for general health, they are not the primary pharmacological agents administered to facilitate the ECT procedure.

D. Carbamazepine is an anticonvulsant, which would counteract the therapeutic goal of ECT by raising the seizure threshold, making it difficult to induce a seizure.

1. Halter, M. J. (2022). Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach (9th ed.). Elsevier. In Chapter 15, "Brain Stimulation Therapies," the section on the ECT procedure details the use of a short-acting anesthetic (e.g., methohexital), a muscle relaxant (e.g., succinylcholine), and an anticholinergic agent (e.g., atropine or glycopyrrolate) (p. 277).

2. American Psychiatric Association. (2001). The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (A Task Force Report of the American Psychiatric Association) (2nd ed.). American Psychiatric Publishing. Chapter 8, "The Practice of ECT," outlines the standard anesthetic management, stating, "The anesthetic technique for ECT consists of the administration of an anticholinergic agent, an anesthetic agent, and a muscle relaxant" (p. 111). It lists atropine, methohexital, and succinylcholine as common examples.

3. Pagnin, D., de Queiroz, V., Pini, S., & Cassano, G. B. (2004). Efficacy of ECT in depression: a meta-analytic review. The Journal of ECT, 20(1), 13-20. https://doi.org/10.1097/00124509-200403000-00004. The "Methods" sections of studies included in this meta-analysis consistently describe the use of a short-acting anesthetic and a muscle relaxant as standard procedure for modified ECT.

The most appropriate statement is one that provides honest, age-appropriate, and sensory-based information without being overly frightening. For a 6-year-old (school-age) child, using familiar terms like "pinch" or "bug bite" helps them understand the sensation they might experience. This approach aligns with the principles of atraumatic care. Asking the child to describe the feeling afterward gives them a sense of control and involvement, which can reduce anxiety and promote coping. This method avoids false reassurance and negative language, fostering trust between the nurse and the child.

B. Stating the procedure will "hurt a lot" is overly negative and will significantly increase the child's fear and anxiety, making cooperation more difficult.

C. Labeling the procedure as "terrible" is unprofessional and introduces a high level of fear. Telling the child not to look can increase anxiety about the unknown.

D. This statement minimizes the child's potential pain, which can lead to a loss of trust. The phrase "be a big boy" is judgmental and discourages the child from expressing their feelings.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's nursing care of infants and children (11th ed.). Elsevier. In Chapter 36, "Pain Assessment and Management in Children," the text emphasizes preparing children for painful procedures by providing factual information in simple terms they can understand, such as describing the sensation as a "pinch" (p. 1045, Box 36.5).

2. Koller, D. (2008). Preparing children for medical procedures. Paediatrics & Child Health, 13(1), 33–36. https://doi.org/10.1093/pch/13.1.33. This article highlights the importance of providing sensory information (what the child will feel, see, hear) and avoiding false reassurance. It supports describing sensations in familiar terms to reduce distress (p. 34, "Provide sensory information").

3. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal child nursing care (5th ed.). Elsevier Mosby. Chapter 32, "Family-Centered Care of the Child During Illness and Hospitalization," advises nurses to "prepare the child for any unfamiliar procedure... by demonstrating on a doll... and describing the sensation—for example, 'a cool feeling when the skin is cleaned'" (p. 921). This supports the use of sensory-based, non-threatening descriptions.

An elective saline abortion involves the intra-amniotic infusion of a hypertonic saline solution. This concentrated salt solution is absorbed into the maternal circulation, leading to a rapid increase in serum sodium levels and plasma osmolality (hypernatremia). The body's primary compensatory mechanism for this hypertonic state is to stimulate the thirst center in the hypothalamus. This intense thirst is a direct and early physiological response aimed at increasing fluid intake to dilute the excess sodium and restore osmotic balance.

A. Water satiety: This is the opposite of the expected effect. The hypertonic state created by the saline infusion triggers a strong thirst mechanism, not a feeling of fullness from water.

C. Edema: While fluid shifts and potential fluid overload can occur, generalized edema is not an early or primary side effect. It would be a later sign of complications like heart failure or renal compromise.

D. Diabetes insipidus: This condition is characterized by excessive water loss due to an antidiuretic hormone (ADH) deficiency. The hypernatremia from saline infusion would stimulate ADH release to conserve water, not cause diabetes insipidus.

1. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education. In Chapter 18, "Abortion," the text discusses complications of various methods, noting that hypertonic saline instillation carries a significant risk of hypernatremia and subsequent central nervous system effects if absorbed systemically. The physiological response to hypernatremia is intense thirst.

2. Mezrow, G., Breen, J. L., & Vujic, I. (1990). Complications of second-trimester abortion by intraamniotic prostaglandin F2alpha and hypertonic saline. Journal of Reproductive Medicine, 35(8), 793-796. This article reviews complications, including the well-documented electrolyte disturbances such as hypernatremia resulting from systemic absorption of the saline, which clinically manifests as thirst.

3. Goodlin, R. C., McLennan, C. E., Choyce, J. M., Lee, R. S., & Stickler, J. E. (1972). The maternal-fetal-amniotic fluid-hypertonic-saline-abortion-syndrome. American Journal of Obstetrics and Gynecology, 114(7), 867-872. https://doi.org/10.1016/0002-9378(72)90169-8. This foundational paper describes the maternal physiologic responses, including a consistent rise in serum sodium and osmolality (p. 868), which is the direct trigger for the thirst mechanism.

Therapeutic play is a primary and highly effective method for helping school-aged children cope with significant emotional stress. Play-acting, or role-playing, allows siblings to express complex feelings such as fear, anger, or guilt in a safe and controlled manner. They can act out scenarios, explore different perspectives, and communicate anxieties they may be unable to verbalize. This active, expressive approach is developmentally appropriate and helps them process the difficult situation of a sibling's terminal illness, promoting understanding and coping.

A. Open discussion and understanding: While important, school-aged children may lack the vocabulary or emotional maturity to fully articulate their complex feelings through direct conversation alone.

C. Storytelling: Bibliotherapy can be a useful tool to normalize feelings, but it is a more passive approach and may not facilitate the direct expression of the child's unique, personal emotions.

D. Drawing pictures: Art therapy is also a valuable tool for non-verbal expression; however, role-playing is often more effective for exploring the specific interpersonal dynamics and communication challenges within the family.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's Nursing Care of Infants and Children (11th ed.). Elsevier. In the chapter on "The Child with a Life-Threatening Condition and End-of-Life Care," the text emphasizes therapeutic play as a key intervention for helping children express feelings and fears they cannot verbalize (See Chapter 17, section on "Interventions").

2. McCarthy, A. M., & Gallo, A. M. (2010). A model of family adaptation to childhood chronic illness. Journal of Pediatric Nursing, 25(5), 401-410. This article discusses the importance of interventions that support family communication. For school-aged siblings, play-based therapies are highlighted as essential for facilitating this communication and emotional expression. https://doi.org/10.1016/j.pedn.2010.04.006

3. Johns Hopkins School of Nursing. (n.d.). Care of the Child and Family Clinical Practicum Course Materials. Courseware often details age-appropriate psychosocial interventions, identifying therapeutic play (including role-playing) as a cornerstone of nursing care for school-aged children experiencing trauma or grief. It allows for mastery and control over overwhelming situations.

4. Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2017). Pediatric Primary Care (6th ed.). Elsevier. The text discusses developmental approaches to communication, noting that for school-aged children, play is a natural medium for expressing thoughts and feelings that are too difficult to state directly (See Chapter 5, "Communication and Interviewing").

An obstructing stone in the renal pelvis or upper ureter causes acute distention of the renal capsule and ureteral spasm, resulting in severe, colicky flank pain known as renal colic. The intensity of this pain often triggers a systemic sympathetic and vagal response via the celiac plexus. This stimulation leads to associated symptoms such as nausea, vomiting, diaphoresis, and pallor. This clinical presentation is the hallmark of an acute upper urinary tract obstruction.

A. Radiating pain to the groin, labia, or testicles is characteristic of a stone that has migrated to the lower third of the ureter.

B. Urinary frequency and dysuria are irritative voiding symptoms that typically occur when the stone is located at the ureterovesical junction, near the bladder.

D. Dull, aching back pain is more often associated with a non-obstructing stone within the renal calyces or a chronic, less severe obstruction.

1. Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier. Chapter 45, Urinary Tract Calculi, Clinical Manifestations section, p. 1031.

2. Johns Hopkins University School of Nursing. (n.d.). Nursing Care of the Patient with Renal Calculi. Courseware, Synthesis Practicum. The course materials describe the classic presentation of renal colic from upper ureteral obstruction as "acute, severe flank pain" accompanied by "nausea, vomiting, and diaphoresis."

3. Tefekli, A., & Cezayirli, F. (2013). The history of urinary stones. Urolithiasis, 41(6), 491–500. https://doi.org/10.1007/s00240-013-0613-8 (This article, in its review of clinical presentation, discusses the pathophysiology of renal colic, linking severe flank pain and associated systemic symptoms like nausea and vomiting to upper ureteral obstruction).

A rectal temperature of 102°F (38.9°C) is a significant finding that requires immediate reporting. A scalp laceration provides a direct portal of entry for microorganisms, placing the client at high risk for a central nervous system infection, such as meningitis or a brain abscess. Fever may be the first sign of such a life-threatening complication. Additionally, a high temperature can indicate hypothalamic dysregulation resulting from the head injury itself. Prompt physician notification is crucial for timely diagnosis and intervention, which may include blood cultures and initiation of antibiotic therapy.

A. This minor blood pressure fluctuation is within the normal range for an adolescent and can be caused by factors like pain or activity; it is not clinically significant.

B. While a headache unresponsive to analgesia is a concern for increasing intracranial pressure, a high fever suggests a new, acute infectious process, which is a more immediate life-threatening emergency.

C. A pulse rate between 68 and 76 bpm is a normal finding for a 14-year-old and does not indicate a complication such as the bradycardia seen with Cushing's triad.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's Nursing Care of Infants and Children (11th ed.). Elsevier. In Chapter 29, "The Child with a Neurologic Condition," the text emphasizes monitoring for signs of infection after head trauma, noting that fever can be an early indicator of meningitis or wound infection (pp. 878-880).

2. Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2021). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (10th ed.). Elsevier. Chapter 45, "Care of Patients with Problems of the Central Nervous System: The Brain," discusses that fever is a common complication after traumatic brain injury and must be reported, as it can indicate infection or hypothalamic damage and increases the metabolic demands of the brain (pp. 955-956).

3. University of Michigan, Department of Neurosurgery. (n.d.). Traumatic Brain Injury (TBI). Courseware materials for medical students and residents. The curriculum highlights that secondary insults after TBI, such as fever (hyperthermia) and infection, worsen patient outcomes and require aggressive management. Monitoring for and reporting fever is a critical nursing responsibility. (Section on Secondary Brain Injury).

Heparin is a potent anticoagulant used to treat thrombophlebitis. Its primary and most dangerous adverse effect is bleeding. An overdose exacerbates this risk, leading to signs of hemorrhage. The nurse must monitor for clinical indicators of excessive anticoagulation. Hematuria (blood in the urine), ecchymosis (unexplained bruising), and epistaxis (nosebleed) are all classic, direct signs of bleeding. Other signs include bleeding gums, tarry stools (melena), and petechiae. Prompt identification of these symptoms is critical for patient safety, especially in the postpartum period where the risk of hemorrhage is already elevated.

A. Dysuria (painful urination) is a classic symptom of a urinary tract infection, not a direct sign of heparin overdose.

B. This option incorrectly includes dysuria. While hematuria and epistaxis are correct, the presence of an incorrect sign makes the entire option less accurate.

C. This option incorrectly includes vertigo. Vertigo is not a primary sign of heparin overdose, though it could be a late symptom of hypovolemia from major blood loss.

1. Lilley, L. L., Rainforth, S. J., & Snyder, J. S. (2021). Pharmacology and the Nursing Process (10th ed.). Elsevier. In Chapter 26, "Anticoagulants," the text identifies bleeding as the main complication of heparin therapy, with signs including hematuria, melena, petechiae, ecchymoses, and gum or mucous membrane bleeding (p. 429).

2. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2018). Maternal Child Nursing Care (6th ed.). Elsevier. In Chapter 22, "Postpartum Complications," the nursing care plan for thromboembolic disease emphasizes assessing for evidence of bleeding, such as bleeding gums, nosebleeds, easy bruising, and hematuria, in clients receiving anticoagulant therapy (p. 549).

3. Hirsh, J., & Raschke, R. (2004). Heparin and Low-Molecular-Weight Heparin: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3suppl), 188S–203S. This guideline identifies bleeding as the major complication of heparin therapy and discusses the clinical spectrum of bleeding events, which includes hematuria and spontaneous ecchymoses. (Section: "Complications of Heparin Therapy," p. 196S). https://doi.org/10.1378/chest.126.3suppl.188s

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The client's elevated blood sugar levels during her current pregnancy, combined with the fact that she only exhibits these signs while pregnant, fits the precise definition of GDM. Her history of delivering a macrosomic infant (weighing 4536 g, which is >4000 g) is a significant risk factor for and a common clinical indicator associated with GDM in a previous pregnancy.

A. Insulin-dependent diabetes: This is an outdated term describing treatment (the need for insulin) rather than the underlying pathophysiology or type of diabetes.

B. Type II diabetes mellitus: This is a chronic metabolic disorder that persists outside of pregnancy. The scenario specifies the client only shows signs of diabetes when she is pregnant.

C. Type I diabetes mellitus: This is an autoimmune condition resulting in absolute insulin deficiency that would be present before, during, and after pregnancy, not just during gestation.

1. American Diabetes Association. (2022). 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2022. Diabetes Care, 45(Supplement1), S17–S38. https://doi.org/10.2337/dc22-S002

Page S27, Section "Gestational Diabetes Mellitus": Defines GDM as "diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation."

2. American College of Obstetricians and Gynecologists (ACOG). (2018). ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics & Gynecology, 131(2), e49-e64. https://doi.org/10.1097/AOG.0000000000002501

Page e50, "Background" section: Lists risk factors for GDM, including a "history of delivering an infant weighing 4,000 g or more."

3. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and pediatric nursing (4th ed.). Wolters Kluwer.

Chapter 21, "Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations," Section "Diabetes Mellitus": Differentiates between pregestational diabetes (Type 1 or Type 2) and gestational diabetes, defining the latter as glucose intolerance that does not extend beyond the pregnancy.

The client's presentation is characteristic of conversion disorder, also known as Functional Neurological Symptom Disorder. This condition involves neurological symptoms, such as blindness, paralysis, or numbness, that cannot be explained by a medical evaluation or neurological condition. The onset of these symptoms is often associated with significant psychological stress or trauma, representing an unconscious "conversion" of emotional distress into a physical symptom. The diagnostic findings of no organic cause for the blindness, coupled with a history of recent trauma, strongly support this diagnosis.

A. Delusion: This is a fixed, false belief (a disturbance in thought content), not a physical sensory symptom like blindness.

B. Illusion: This is a misinterpretation of a real external sensory stimulus, such as seeing a shadow and thinking it is a person.

C. Hallucination: This is a false sensory perception without any real external stimulus, such as hearing voices when no one is present.

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). As cited in: Tollefson, J., & Bishop, L. (2021). Psychiatric-Mental Health Nursing: Foundational Concepts. University of West Florida Pressbooks. Chapter 10, "Somatic Symptom and Related Disorders," Section on Functional Neurological Symptom Disorder (Conversion Disorder). (This university courseware explains that the disorder involves one or more symptoms of altered voluntary motor or sensory function, with clinical findings showing incompatibility between the symptom and recognized neurological or medical conditions).

2. Aybek, S., & Perez, D. L. (2022). The clinical evaluation of functional neurological disorder. JAMA Neurology, 79(2), 203–212. https://doi.org/10.1001/jamaneurol.2021.4598 (This peer-reviewed article discusses the diagnostic criteria, emphasizing the essential rule-out of neurological disease and the frequent association with psychological stressors. See "Clinical Evaluation" section).

3. Reeves, R. R., & Ros-Rull, G. (2018). Differentiating Somatic Symptom Disorder, Functional Neurological Symptom Disorder, and Malingering. The Journal of the American Academy of Psychiatry and the Law, 46(3), 386–389. https://doi.org/10.29158/JAAPL.003781-18 (This publication clarifies the distinction between conversion disorder and other conditions, highlighting the lack of an organic basis for the neurological symptom).

The client is multiparous, fully dilated, and verbalizing the sensation of imminent birth ("the baby is coming"). This combination of factors strongly suggests the second stage of labor is progressing rapidly and birth is imminent. The nurse's immediate priority is to perform a rapid assessment to validate the client's statement. Inspecting the perineum for bulging or crowning of the fetal head is the most direct and definitive way to confirm this. This visual assessment will guide the nurse's next immediate actions, such as calling for assistance, providing perineal support, and preparing for an emergency delivery if the provider is not present.

B. Time the contractions.

Timing contractions is a key assessment during the first stage of labor but is a lower priority when birth is imminent in the second stage.

C. Prepare a sterile area for delivery.

This is an important intervention, but it must follow an assessment. The nurse must first confirm that birth is imminent before preparing the area.

D. Auscultate for fetal heart rate (FHR).

While monitoring FHR is crucial, visually confirming an impending birth takes precedence to prevent an uncontrolled delivery and ensure the safety of both mother and baby.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity & women's health care (12th ed.). Elsevier. In Chapter 17, "Nursing Care During Labor and Birth," the section on the Second Stage of Labor emphasizes that when a woman has a strong urge to push, the nurse should assess for perineal bulging and crowning as signs of imminent birth (pp. 408-409).

2. Durham, R. F., & Chapman, L. (2019). Maternal-newborn nursing: The critical components of nursing care (3rd ed.). F.A. Davis Company. Chapter 10, "Nursing Care During Labor and Birth," states that if a woman says, "The baby is coming," the nurse's first action should be to assess the perineum for crowning to prepare for imminent birth (p. 221, "Nursing Actions for Imminent Birth").

3. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and pediatric nursing (4th ed.). Wolters Kluwer. Chapter 14, "Nursing Management During Labor and Birth," details the assessment during the second stage of labor, prioritizing the observation of perineal bulging and the visualization of the fetal head as indicators for immediate delivery preparations (p. 512).