NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
Correct Answer: D
Rationale: If the child is obtunded, the child sleeps unless aroused and, when aroused, has limited interaction with the environment. The remaining options describe confusion, disorientation, and stupor.
Question 2 of 5
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
Question 3 of 5
A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.
Question 4 of 5
The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted?
Correct Answer: D
Rationale: Oxytocin is a uterine stimulant. During an oxytocin infusion, the woman is monitored closely for signs of water intoxication, including tachycardia, cardiac dysrhythmias, shortness of breath, nausea, and vomiting. The remaining options are not associated with water intoxication.
Question 5 of 5
A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance?
Correct Answer: D
Rationale: Assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The assessment findings in the remaining options are not associated with dehydration.