NCLEX-RN
RN Reduction of Risk Potential NCLEX Questions
Extract:
Question 1 of 5
A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?
Correct Answer: D
Rationale: Bulging fontanels and increased head circumference (
D) suggest intracranial hemorrhage, a hallmark of shaken baby syndrome in infants.
Question 2 of 5
A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?
Correct Answer: D
Rationale: Bulging fontanels and increased head circumference (
D) suggest intracranial hemorrhage, a hallmark of shaken baby syndrome in infants.
Question 3 of 5
The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.
Correct Answer: A,B
Rationale: Thrombocytopenia causes bleeding tendencies like epistaxis (
A) and petechiae (
B). Vomiting blood (
C) is less common, and hematocrit (
D) and platelets (E) are decreased, not elevated.
Question 4 of 5
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
Correct Answer: A
Rationale: The correct order is inspection, auscultation, palpation, percussion to avoid altering bowel sounds with palpation or percussion before auscultation.
Question 5 of 5
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply.
Correct Answer: B,D
Rationale: Rising ammonia in cirrhosis causes encephalopathy, so rest (
B) and monitoring mental status (
D) are needed. Straight razors (
A) increase bleeding risk, and potassium restriction (
C) is unrelated.