NCLEX Questions, NCLEX PN Exam Practice Test with NGN Questions, NCLEX-PN Questions, Nurselytic

Questions 85

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Exam Practice Test with NGN Questions

Extract:

The nurse is caring for an infant in the clinic.
Nurses' Notes Clinic Visit: Age 4 Months
0800: The infant is playing with the hands and feet and making cooing sounds. The infant smiles and laughs appropriately when the caregiver provides a toy. No evidence of Moro, tonic, or rooting reflexes noted. The infant has weak muscle tone in the neck and does not hold the head up independently.
Clinic Visit: Age 6 Months
0930: The infant does not have head control. The caregiver reports that the infant babbles but does not use words or call the parent by any name. The infant does not point at desired objects. The caregiver also reports that the infant has begun to act afraid of unfamiliar people


Question 1 of 5

The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........

Correct Answer: B,D

Rationale: Lack of head control at 6 months is concerning for cerebral palsy , as it indicates delayed motor development.

Extract:

The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased


Question 2 of 5

For each finding below, click to specify if the finding is consistent with the disease process of Guillain-Barré syndrome, ischemic brain stroke, or lumbar disk herniation.

FindingGuillain-Barré SyndromeIschemic Brain StrokeLumbar Disk Herniation
Radiating back pain
Difficulty swallowing
Recent viral infection
Ascending muscle weakness

Correct Answer: A,B,C,D

Rationale: Radiating pain is typical of disk herniation, swallowing issues occur in GBS and stroke, viral history and ascending weakness are specific to GBS.

Extract:

The nurse is caring for an infant in the clinic.
Nurses' Notes Clinic Visit: Age 4 Months
0800: The infant is playing with the hands and feet and making cooing sounds. The infant smiles and laughs appropriately when the caregiver provides a toy. No evidence of Moro, tonic, or rooting reflexes noted. The infant has weak muscle tone in the neck and does not hold the head up independently.
Clinic Visit: Age 6 Months
0930: The infant does not have head control. The caregiver reports that the infant babbles but does not use words or call the parent by any name. The infant does not point at desired objects. The caregiver also reports that the infant has begun to act afraid of unfamiliar people


Question 3 of 5

The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........

Correct Answer: B,D

Rationale: Lack of head control at 6 months is concerning for cerebral palsy , as it indicates delayed motor development.

Extract:

The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine


Question 4 of 5

The client is most likely experiencing ....... and is at risk for.......

Correct Answer: C,E

Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.

Extract:

The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur


Question 5 of 5

For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism, myocardial infarction, or panic disorder.

FindingHyperthyroidismMyocardial InfarctionPanic Disorder
Diaphoresis
Trembling hands
Heart palpitations
Shortness of breath

Correct Answer: A,B,C,D

Rationale: Diaphoresis , palpitations , and shortness of breath occur in all three. Trembling hands are specific to hyperthyroidism and panic disorder.

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