NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe?
Correct Answer: D
Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. A rash, dermatitis, and reddened skin may occur with external radiation, but these conditions are not described as moist desquamation.
Question 2 of 5
When assessing a child which finding would indicate the presence of Kernig's sign?
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.
Question 3 of 5
The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted?
Correct Answer: D
Rationale: Oxytocin is a uterine stimulant. During an oxytocin infusion, the woman is monitored closely for signs of water intoxication, including tachycardia, cardiac dysrhythmias, shortness of breath, nausea, and vomiting. The remaining options are not associated with water intoxication.
Question 4 of 5
Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?
Correct Answer: D
Rationale: Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option 1 is a clinical manifestation of lactose intolerance. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease.
Question 5 of 5
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.
Therefore, the remaining options are incorrect.