Quizlet NCLEX PN 2023 - Nurselytic

Correct Answer: B

Rationale: The correct answer is 'Increased pupil size bilaterally.' When assessing for signs of increased intracranial pressure, bilateral pupil dilation is not typically associated with this condition. Instead, unilateral pupil changes, especially one pupil becoming dilated or non-reactive while the other remains normal, are indicative of increased ICP. Bradycardia, a change in level of consciousness (LO
C), and vomiting are commonly seen in patients with increased intracranial pressure due to the brain's response to the rising pressure.
Therefore, the presence of bilateral pupil dilation goes against the typical pattern observed in patients with increased intracranial pressure.

Correct Answer: D

Rationale: The correct answer is 'Eyedrops are required by law every 6 hours following birth.' This statement is inaccurate because while laws do require the placement of eyedrops, physicians indicate a specific timeframe for their administration.
Choice A is correct because eyedrops following birth do help reduce the risk of eye infection by preventing ophthalmia neonatorum.
Choice B is incorrect as it implies that eyedrops are mandated solely by law, without considering medical reasons.
Choice C is accurate as eyedrops do help keep the eye moist, preventing dryness and discomfort.

Correct Answer: C

Rationale: Acinar cells are responsible for creating exocrine secretions, such as enzymes and digestive juices. Alpha cells are found in the pancreas and are responsible for producing glucagon, beta cells produce insulin, and plasma cells are a type of white blood cell involved in immune responses.
Therefore, the correct answer is acinar cells, as they specifically produce exocrine secretions.

Correct Answer: C

Rationale: A client newly diagnosed with Diabetes Mellitus requires education on managing their condition.
Choice C is the correct answer because it emphasizes the importance of a comprehensive approach involving both diet and exercise. This holistic approach is crucial in managing blood sugar levels and overall health for individuals with diabetes.
Choice A is incorrect as it provides misleading information by suggesting that the client can eat anything as long as it doesn't contain sugar, which is not accurate for diabetes management.
Choice B is not the best option as it focuses solely on weight loss rather than addressing the holistic needs of a diabetic individual.
Choice D is incorrect as it suggests eliminating all salt, fat, and sugar, which is an extreme approach and not a realistic or balanced way to manage diabetes.

Correct Answer: D

Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety.
Choice A is incorrect because solely noting the drug given does not address the severity of the error.
Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention.
Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.