NCLEX-RN
Results Analysis Questions
Extract:
Question 1 of 5
A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating?
Correct Answer: C
Rationale: After a thrombotic stroke, the client often experiences periods of emotional lability, which are characterized by sudden bouts of laughing or crying or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture of the client with this health problem, although it may be difficult for health care personnel and family members to deal with it. The other options are incorrect.
Question 2 of 5
The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis?
Correct Answer: C
Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein and low glucose.
Therefore, options 1, 2, and 4 are incorrect.
Question 3 of 5
The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?
Correct Answer: B
Rationale: Absence seizures are a type of generalized seizure. They consist of a sudden, brief (usually 5 to 10 seconds) arrest of the child's motor activities accompanied by a blank stare and a loss of awareness. The child's posture is maintained at the end of the seizure, and the child returns to activity that was in process as though nothing has happened. School phobia includes physical symptoms that usually occur at home and that may prevent the child from attending school. Behavior problems would be noted by more overt symptoms than the ones described in this question. A child with attention-deficit/hyperactivity syndrome becomes easily distracted, is fidgety, and has difficulty following directions.
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
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.