NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
Correct Answer: C
Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage.
Choice A is incorrect as the presentation is not consistent with chickenpox.
Choice B is incorrect because impetigo is contagious, especially through direct contact.
Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.
Question 2 of 5
The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
Correct Answer: A
Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep.
Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.
Question 3 of 5
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
Correct Answer: C
Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage.
Choice A is incorrect as the presentation is not consistent with chickenpox.
Choice B is incorrect because impetigo is contagious, especially through direct contact.
Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.
Question 4 of 5
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
Correct Answer: D
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content.
Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy.
Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.
Question 5 of 5
When are pressure ulcers most likely to occur?
Correct Answer: A
Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer.
Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client.
Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.