NCLEX-RN
Results Analysis Questions
Extract:
Question 1 of 4
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
Question 2 of 4
The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis?
Correct Answer: C
Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein and low glucose.
Therefore, options 1, 2, and 4 are incorrect.
Question 3 of 4
A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?
Correct Answer: D
Rationale: Shock may be classified as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure remains normal. The capillary refill time may be prolonged and more than 2 seconds, and the child may become irritable as a result of increasing hypoxia. The most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock; rather, it is a cause of the fluid and electrolyte imbalance.
Question 4 of 4
The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?
Correct Answer: B
Rationale: Absence seizures are a type of generalized seizure. They consist of a sudden, brief (usually 5 to 10 seconds) arrest of the child's motor activities accompanied by a blank stare and a loss of awareness. The child's posture is maintained at the end of the seizure, and the child returns to activity that was in process as though nothing has happened. School phobia includes physical symptoms that usually occur at home and that may prevent the child from attending school. Behavior problems would be noted by more overt symptoms than the ones described in this question. A child with attention-deficit/hyperactivity syndrome becomes easily distracted, is fidgety, and has difficulty following directions.
Question 5 of 4
A 3-week-old infant is brought to the well-baby clinic for a phenylketonuria (PKU) screening test. The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL (60 mmol/L). What is the nurse's priority action?
Correct Answer: A
Rationale: The normal PKU level is 0.8 to 1.8 mg/dL (48 to 109 mmol/L). With early postpartum discharge, screening is often performed when the infant is less than 2 days old because of the concern that the infant will be lost to follow-up. Infants should be rescreened by the time that they are 14 days old if the initial screening was done when the infant was 24 to 48 hours old.