NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
Question 2 of 5
A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). On the basis of the developmental stage of the infant, what intervention should the nurse include in the plan of care?
Correct Answer: D
Rationale: A 10-month-old infant is in the trust versus mistrust stage of psychosocial development, according to Erik Erikson, and the sensorimotor period of cognitive development, according to Jean Piaget. Hospitalization may have an adverse effect. A consistent routine accompanied by touching, rocking, and cuddling will help the child develop trust and provide sensory stimulation.
Total body restraint is unnecessary and an incorrect action.
Touching and holding the infant only when the parents visit will not provide adequate stimulation and interpersonal contact for the infant. RSV is not airborne (a mask is not required), and it is usually transmitted by the hands.
Question 3 of 5
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
Question 4 of 5
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
Correct Answer: D
Rationale: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.
Question 5 of 5
The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
Correct Answer: D
Rationale:
To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.