NCLEX-RN
Results Analysis Questions
Extract:
Question 1 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 2 of 5
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
Question 3 of 5
At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?
Correct Answer: C
Rationale: Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function that is frequently noted with a fetus of more than 38 weeks' gestation. Fresh meconium, in combination with late decelerations and a variable descending baseline, is an ominous signal of fetal distress caused by fetal hypoxia. It is not unusual for the fetal heart rate to drop to less than the 140 to 160 beats/min range in late labor during contractions, and, in a healthy fetus, the fetal heart rate will recover between contractions. Old meconium staining may be the result of a prenatal trauma that is resolved.
Question 4 of 5
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
Question 5 of 5
A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support?
Correct Answer: B
Rationale: Signs and symptoms of cholinergic crisis include nausea, vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, pupillary miosis, and hypotension. It is caused by overmedication with cholinergic (anticholinesterase) medications, and it is treated by withholding medications. Myasthenic crisis is an exacerbation of myasthenic symptoms caused by undermedication with anticholinesterase medications. There are no data in the question to support the remaining options.