Questions 83

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Questions Exam Cram Questions

Question 1 of 5

A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

Correct Answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (
Choice
B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (
Choice
C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (
Choice
D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

Question 2 of 5

The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?

Correct Answer: D

Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.

Question 3 of 5

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

Correct Answer: C

Rationale: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases, the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the groin area (
Choice
A) is not recommended as it will not help in the resolution of the hydrocele. Referral to a surgeon (
Choice
B) is not necessary at this stage since hydroceles often resolve on their own in infants. Keeping the infant in a flat, supine position (
Choice
D) does not aid in the reabsorption of fluid and is not a recommended intervention for hydrocele management.

Question 4 of 5

A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?

Correct Answer: C

Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency.
Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin.
Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency.
Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.

Question 5 of 5

Parents of a 6-month-old breastfed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?

Correct Answer: A

Rationale: The correct answer is 'Cereal.' The guidelines of the American Academy of Pediatrics recommend introducing one new food at a time, starting with strained cereal. Cereal is often recommended as a first solid food for infants due to its soft texture and iron-fortified properties, which are important for the baby's development. Eggs and meat are common allergenic foods and are usually introduced later. Juice is not recommended for infants under 1 year old due to its high sugar content and lack of nutritional value compared to whole fruits.

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