NCLEX-PN
Nclex Practice Questions 2024 Questions
Extract:
Question 1 of 5
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
Correct Answer: A
Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.
Question 2 of 5
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
Correct Answer: B
Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice
A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice
C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice
D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.
Question 3 of 5
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
Correct Answer: C
Rationale: The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.
Question 4 of 5
A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information?
Correct Answer: B
Rationale: The correct answer is B: 'Egg white should not be given to my infant because of the risk for an allergy.' Egg white, even in small quantities, is not recommended for infants until the end of the first year of life due to its common allergenic potential.
Choice A is incorrect because while meats are important for iron, they are not typically introduced to infants until around 6-8 months.
Choice C is incorrect because food should never be mixed with formula in the bottle as it may lead to feeding difficulties and inaccurate monitoring of intake.
Choice D is incorrect because fluoride supplementation may be required around 6 months depending on the infant's fluoride intake from water. Introducing solid foods like rice cereal, fruits, or vegetables is usually done around 5-6 months, following healthcare provider recommendations.
Question 5 of 5
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
Correct Answer: B
Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse.
Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.