NCLEX-RN
Planning Questions
Extract:
Question 1 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 2 of 5
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
Correct Answer: B
Rationale: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.
Question 3 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.
Question 4 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 5 of 5
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.