NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?
Correct Answer: A
Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.
Question 2 of 5
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
Correct Answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
Question 3 of 5
One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?
Correct Answer: C
Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice
A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice
B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice
D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.
Question 4 of 5
A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
Correct Answer: D
Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
Question 5 of 5
The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?
Correct Answer: D
Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color.
Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.