NCLEX-RN
Results Analysis Questions
Question 1 of 5
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?
Correct Answer: B
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve. The remaining options identify early signs of a deteriorating level of consciousness.
Question 2 of 5
What is the nurse's priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)?
Correct Answer: C
Rationale: After IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. The client is usually allowed activity as tolerated, without any specific activity guidelines. It is unnecessary to void frequently after the procedure.
Question 3 of 5
The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?
Correct Answer: C
Rationale: The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction that accompanies this disorder and from the normally decreased ability of the neonate's liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. The white blood cell count is not related to this disorder.
Question 4 of 5
A child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. The child has been experiencing fever, malaise, anorexia, and a headache. Which diagnostic study will confirm the diagnosis?
Correct Answer: A
Rationale: The diagnosis of bacterial endocarditis is primarily established on the basis of a positive blood culture of the organisms and the visualization of vegetation on echocardiographic studies. Other laboratory tests that may help confirm the diagnosis are an elevated sedimentation rate and the C-reactive protein level. An ECG is not usually helpful for the diagnosis of bacterial endocarditis.
Question 5 of 5
The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?
Correct Answer: B
Rationale: Absence seizures are a type of generalized seizure. They consist of a sudden, brief (usually 5 to 10 seconds) arrest of the child's motor activities accompanied by a blank stare and a loss of awareness. The child's posture is maintained at the end of the seizure, and the child returns to activity that was in process as though nothing has happened. School phobia includes physical symptoms that usually occur at home and that may prevent the child from attending school. Behavior problems would be noted by more overt symptoms than the ones described in this question. A child with attention-deficit/hyperactivity syndrome becomes easily distracted, is fidgety, and has difficulty following directions.