NCLEX-PN
2024 PN NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?
Correct Answer: D
Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as 'Mama,' 'Daddy,' 'bye-bye,' and 'baby,' begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age.
Therefore, the milestone of the infant saying 'Mama' is the most appropriate for a 9-month-old, indicating early language development. The other choices are developmentally inaccurate for a 9-month-old infant.
Question 2 of 5
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
Correct Answer: A
Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication.
Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns.
Choices B, C, and D contain some truths but are not the most therapeutic responses.
Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways.
Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity.
Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.
Question 3 of 5
A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
Correct Answer: B
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse.
Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate.
Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR.
Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart.
Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
Question 4 of 5
A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?
Correct Answer: B
Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being.
Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context.
Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.
Question 5 of 5
How should a client's neck be positioned for palpation of the thyroid?
Correct Answer: A
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.