ATI RN
Pediatric NCLEX Questions Questions
Question 1 of 5
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
Correct Answer: B
Rationale: Fatigue in a patient with heart failure is commonly caused by decreased cardiac output. In heart failure, the heart is unable to pump enough blood to meet the body's demands, resulting in reduced delivery of oxygen and nutrients to the tissues. This can lead to generalized weakness and fatigue. Dyspnea (choice A) is commonly associated with heart failure but is more specific to difficulty breathing, while a dry cough (choice C) is a symptom that can be present but is not typically the primary cause of fatigue. Orthopnea (choice D) is a symptom of heart failure characterized by difficulty breathing when lying flat but is not directly related to the patient's increasing fatigue in this scenario.
Question 2 of 5
Which of the ff is a nursing intervention when assessing clients with hypertension?
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.
Question 3 of 5
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
Question 4 of 5
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
Correct Answer: D
Rationale: The best way to assess whether a patient is breathing is to observe the movement of the chest and nostrils. Chest movement indicates inhalation and exhalation, while the nostrils may flare during breathing. Observing these two areas provides a more direct and accurate assessment of breathing compared to extremities, head, or eyeball movements. By focusing on the chest and nostrils, a nurse can quickly and effectively determine if a patient is breathing adequately.
Question 5 of 5
A 39 y.o. homemaker sees her physician after she falls twice for seemingly no reason. Diagnostic tests are done, and she is diagnosed with multiple sclerosis. Which of the ff. explanations will help her understand her disease?
Correct Answer: D
Rationale: Option D, "The insulation on your nerve cells is damaged, which slows the impulses to the muscles," is the most accurate explanation for multiple sclerosis. Multiple sclerosis is a chronic autoimmune disorder where the body's immune system mistakenly attacks the myelin sheath, the protective covering of nerve fibers in the central nervous system. This damage disrupts the normal flow of electrical impulses along the nerves, leading to various symptoms such as muscle weakness, coordination problems, and balance issues. By understanding that the insulation on her nerve cells is damaged, the patient can better comprehend why she is experiencing symptoms like muscle weakness and falls.