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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

The nurse on the psychiatric unit is caring for several clients. Which client needs the most immediate attention?

Correct Answer: C

Rationale: Screaming and running indicate potential danger to self or others, requiring immediate intervention to ensure safety.

Question 2 of 5

A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best response to this request?

Correct Answer: C

Rationale: Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting sodium, fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is appropriate for this age.

Question 3 of 5

Which finding in a neonate suggests hypothermia?

Correct Answer: A

Rationale: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver.

Question 4 of 5

The nurse is caring for a preschool-aged child admitted with a diagnosis of suspected child abuse. During painful procedures, the child remains quiet and watchful. When planning the care of a victim of child abuse, the nurse should give priority to:

Correct Answer: B

Rationale: Assigning a consistent caregiver will best meet the child's need for safety and security. Playtime will be therapeutic for the child, but it does not have to be with same-age children, so answer A is incorrect. Answer C is too threatening to the child who has been abused, so it is incorrect. Answer D does not allow the child the chance to respond in an expected way, so it is incorrect.

Extract:

A mother with cystic fibrosis child is receiving health teaching from the nurse regarding danger signs of her illness.


Question 5 of 5

The mother has best understood the teaching when she says:

Correct Answer: C

Rationale: Respiratory distress, indicated by tiredness, is a critical danger sign in cystic fibrosis.

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