NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
Correct Answer: B
Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.
Question 2 of 5
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
Correct Answer: C
Rationale: In this case, the correct answer is autonomic neuropathy. Autonomic neuropathy affects the autonomic nerves, which control various bodily functions including the bladder. In diabetes, it can lead to bladder paralysis, resulting in symptoms like urgency to urinate and difficulty initiating urination. Atherosclerosis (choice
A) is a condition involving the hardening and narrowing of arteries, not directly related to the inability to urinate in this context. Diabetic nephropathy (choice
B) primarily affects the kidneys, leading to kidney damage, but does not typically cause urinary retention. Somatic neuropathy (choice
D) involves damage to sensory nerves, not the autonomic nerves responsible for bladder control, making it less likely to be the cause of the urinary issue described in the question.
Question 3 of 5
In a pediatric clinic, a nurse is assessing a child recently diagnosed with cystic fibrosis. Which of the following later findings of this disease would the nurse not expect to see at this time?
Correct Answer: C
Rationale: In a child newly diagnosed with cystic fibrosis (CF), noisy respirations and a dry, non-productive cough are typically the first respiratory signs to appear. The other options, including a positive sweat test, bulky greasy stools, and meconium ileus, are among the earliest findings of CF. CF is a genetic condition that affects the production of mucus, sweat, saliva, and digestive juices. Due to a defective gene, these secretions become thick and sticky instead of thin and slippery, leading to blockages in various passageways, especially in the pancreas and lungs. Respiratory failure is a severe consequence of CF, making it crucial to monitor respiratory symptoms closely in affected individuals.
Therefore, a moist, productive cough would not be an expected finding in a newly diagnosed child with CF.
Question 4 of 5
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
Correct Answer: D
Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.
Question 5 of 5
A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
Correct Answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.