NCLEX Questions, NCLEX-RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

NCLEX-RN Test Bank

NCLEX-RN Exam Questions

Extract:


Question 1 of 5

The nurse has just received the change of shift report. Which client should the nurse assess first?

Correct Answer: B

Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.

Question 2 of 5

A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

Correct Answer: D

Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.

Question 3 of 5

A client with a history of hyperparathyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:

Correct Answer: A

Rationale: Hyperparathyroidism increases parathyroid hormone, leading to hypercalcemia, causing fatigue and other symptoms.

Question 4 of 5

The nurse is caring for a client with a history of a fractured ankle who is in a cast. The client complains of numbness and tingling. The nurse should:

Correct Answer: C

Rationale: Numbness and tingling suggest neurovascular compromise (e.g., compartment syndrome), requiring immediate physician notification. Ice, elevation, and massage are insufficient.

Question 5 of 5

A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?

Correct Answer: A

Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.

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