NCLEX-PN Quizlet 2023 - Nurselytic

Correct Answer: B

Rationale: In this scenario, the symptoms of fever, liver abnormalities, rash, and diarrhea in an immunocompromised client a month after a blood transfusion are indicative of graft-versus-host disease (GVH
D). GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can manifest within a month of the transfusion. While choices 1 and 4 are plausible, it is crucial for the nurse to consider the possibility of GVHD in immunocompromised transfusion recipients due to the significant risk. Myelosuppression, choice C, typically presents with decreased blood cell counts and is not consistent with the symptoms described. An allergic reaction to medication, choice D, would present with different manifestations such as itching, hives, or anaphylaxis, which are not described in the scenario.

Correct Answer: A

Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.

Correct Answer: B

Rationale: Object permanence occurs when the infant learns that something or someone still exists even though they might not be able to see it or them. This typically develops between 9 and 10 months of age. The correct answer, 'The infant looks at the floor to find a toy that he was playing with and dropped,' demonstrates object permanence as the infant understands that the toy still exists even though it is temporarily out of sight.

Choices A and C do not directly relate to object permanence as the behaviors described do not necessarily indicate an understanding of objects existing when out of sight.
Choice D is incorrect as participating in a game of patty-cake does not involve demonstrating object permanence. Peek-a-boo is a more suitable example of a game that demonstrates object permanence, as the infant continues to look for the hidden face, understanding that it still exists even though temporarily unseen.

Correct Answer: B

Rationale: The chain of infection refers to the sequence required for the transmission of disease, involving steps like the pathogen's presence, movement from a reservoir, and entry into a susceptible host. Understanding this sequence helps healthcare professionals, including nurses, in implementing effective infection control measures.

Choices A, C, and D are incorrect because they do not accurately describe the concept of the chain of infection.
Choice A is too broad and does not specifically address the sequential nature of disease transmission.
Choice C focuses on bacterial clustering rather than the transmission process.
Choice D mentions virulence patterns, which are not the primary focus of the chain of infection concept.

Correct Answer: C

Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (
Choice
A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (
Choice
B) is recommended to prevent gum bleeding. Avoiding IM injections (
Choice
D) is crucial to reduce the risk of bleeding in a client with a low platelet count.
Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.