NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?
Correct Answer: A
Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb.
Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk.
Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk.
Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.
Question 2 of 5
A child has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
Correct Answer: C
Rationale: The correct answer is that nonsteroidal anti-inflammatory drugs are the first choice in treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs are important as a first-line treatment and typically require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized.
Choice A is incorrect as early treatment can improve outcomes and prevent joint deformities.
Choice B is incorrect as juvenile idiopathic arthritis does not necessarily progress to adult rheumatoid arthritis.
Choice D is incorrect as physical activity should be encouraged in children with arthritis to maintain joint mobility and overall health.
Question 3 of 5
A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
Correct Answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.
Question 4 of 5
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
Correct Answer: D
Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.
Question 5 of 5
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
Correct Answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV.
Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes.
Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.