NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
Correct Answer: A
Rationale: The correct answer is A: Unequal leg length. In developmental dysplasia of the hip, there is abnormal development of the hip joint. This can lead to unequal leg lengths due to hip instability and dislocation. Limited adduction may be present due to hip joint abnormalities. Diminished femoral pulses are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds are usually present in healthy infants.
Question 2 of 5
The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
Correct Answer: A
Rationale: The correct answer is A: A 26-year-old woman who had a bowel resection. This choice is appropriate for the Women's Health Center as it aligns with the specialization of the unit in women's health. The patient's condition is surgical in nature, which can be managed effectively in a women's health unit that likely has the necessary resources and expertise to care for post-surgical patients.
Choice B: A 40-year-old man who underwent a hernia repair, is incorrect because it is not aligned with the specialization of the Women's Health Center.
Choice C: A 31-year-old woman with septicemia and on a ventilator, is incorrect because this patient requires intensive care and support beyond what a women's health unit can provide.
Choice D: A 91-year-old man with Alzheimer's disease recovering from a fall, is incorrect because this patient's needs are more aligned with geriatric care rather than women's health.
Question 3 of 5
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future.
Choice B shows anger and isolation, not necessarily suicidal ideation.
Choice C demonstrates anger but no indication of suicidal thoughts.
Choice D shows anger towards the roommate, not self-harm intentions.
Question 4 of 5
Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
Correct Answer: B
Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice
A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice
C) and dopamine system stabilizers (choice
D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs.
Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.
Question 5 of 5
Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
Correct Answer: B
Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.
Choice A is part of the assessment phase, which occurs before the intervention phase.
Choice C involves goal-setting, which is part of the planning phase.
Choice D pertains to discharge planning, which is part of the evaluation phase.
In summary,
Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.