NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?
Correct Answer: B
Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Option 1 describes chorea. Option 3 describes polyarthritis. Option 4 describes erythema marginatum.
Question 2 of 5
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
Correct Answer: B
Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.
Question 3 of 5
The nurse plans care for a client with alcohol abuse disorder based on which support system?
Correct Answer: D
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for the parents of children who abuse substances.
Question 4 of 5
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.
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.