ATI RN
NCLEX RN Pediatric Questions Questions
Question 1 of 5
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
Question 2 of 5
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, "This must be a mistake. No one in my family has ever had diabetes." Based on this statement, the nurse suspects the client is using which coping mechanism?
Correct Answer: A
Rationale: The client's response of stating that diabetes cannot be possible because it is not prevalent in the family indicates that the client is using the coping mechanism of denial. Denial is a common defense mechanism where individuals refuse to accept reality or facts that are too uncomfortable for them to acknowledge. In this situation, the client is denying the diagnosis of diabetes as a way to cope with the distressing news, hoping that it may not be true because it has not affected their family members in the past. Recognizing this coping mechanism is important for the nurse to provide support and education to help the client come to terms with the diagnosis and start managing the condition effectively.
Question 3 of 5
A 27-year old adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nutritional health?
Correct Answer: A
Rationale: Anthropometric measurements, such as height, weight, body mass index (BMI), and waist circumference, are essential in assessing the nutritional health of a patient with Crohn's disease. These measurements provide objective data about the patient's nutritional status, body composition, and risk for malnutrition. Monitoring changes in these measurements over time can help identify nutritional deficiencies, weight loss, or malnutrition in patients with Crohn's disease. Dry skin, bleeding gums, and facial rubor can be symptoms of other health conditions, but anthropometric measurements directly assess the nutritional health of the patient.
Question 4 of 5
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
Correct Answer: C
Rationale: When using crutches after an above the knee amputation, it is important for the client to support their weight primarily on their elbows. Placing the weight on the elbows helps to prevent pressure on the axilla (armpit area), which can lead to nerve damage and discomfort. Supporting weight on the elbows also provides better stability and control while using crutches, allowing the client to move more safely and comfortably. Additionally, distributing the weight onto the elbows helps to avoid potential strain and injury to the hands or upper arms.
Question 5 of 5
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: In this situation where Mr. Mariano has an open fracture of the left humerus, the nurse's critical assessment finding should be the status of the client's tetanus immunization. An open fracture poses a risk of infection, and tetanus is a concern due to the potential exposure to bacteria from the environment causing tetanus. Tetanus is a serious bacterial infection that affects the nervous system and can be fatal if not treated promptly. Knowing the client's tetanus immunization status will help determine the need for a tetanus booster to prevent this potentially life-threatening infection. Blood alcohol level, support systems at home, and voiding time are important assessments as well, but in the case of an open fracture, the priority is to assess the risk of tetanus infection.