NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse's assessment?
Correct Answer: B
Rationale:
To evaluate the client's functional status, the nurse assesses the client's ability to perform self-care or ADLs, including bathing, toileting, ambulating, dressing, and feeding. Everyday routines, household management, and physical condition are not components of functional status.
Question 2 of 5
When assessing a child which finding would indicate the presence of Kernig's sign?
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.
Question 3 of 5
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
Question 4 of 5
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.
Therefore, the remaining options are incorrect.
Question 5 of 5
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.