NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a toddler who is assessed as having hypertonicity, delayed fine motor skills, and poor control of coordinated motion. This is indicative of what cerebral palsy (CP) classification? Select all that apply.
Correct Answer: C,E
Rationale: Spastic cerebral palsy is characterized by hypertonicity and poor coordination. Abnormal involuntary or wormlike movements suggest dyskinetic CP, and gross motor impairment is not specified here.
Question 2 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.
Question 3 of 5
A 10-year-old child is diagnosed with pediculosis. The mother is concerned about the spread of the lice to children who have been in contact with her child. The nurse should instruct the mother to have her child avoid:
Correct Answer: C
Rationale: Sharing batting helmets can spread lice through direct head-to-head contact or shared items, unlike the other activities.
Question 4 of 5
The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities? Refer to the figure.
Correct Answer: A
Rationale: Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. All of the conditions that are identified in the options can occur in rheumatoid arthritis; however, the figure pictures ulnar drift.
Question 5 of 5
The nurse is assessing fetal position in a 32-year-old woman in her eighth month of pregnancy. From the fi gure below, the fetal position can be described as:
Correct Answer: D
Rationale: In right occipital anterior lie, the occiput faces the right anterior segment of the woman’s pelvis. In left occipital transverse lie, the occiput faces the woman’s left hip. In left occipital anterior lie, the occiput faces the left anterior segment of the woman’s pelvis. In right occipital transverse lie, the occiput faces the woman’s right hip.