NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately.

Choices A, C, and D are incorrect.
Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method.
Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates.
Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.

Correct Answer: A

Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.

Correct Answer: C

Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses.
Choice A is a closed-ended question since it seeks a specific time for the medication intake.
Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response.
Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.

Correct Answer: B

Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.

Correct Answer: A

Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain.
Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands.
Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function.
Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'