Quizlet NCLEX PN 2023 - Nurselytic

Correct Answer: D

Rationale: The best lab test to diagnose disseminated intravascular coagulation (DI
C) is the D-dimer test. In DIC, numerous small clots form throughout the body and are rapidly broken down. D-dimer measures a specific fibrin split product and is the most specific test for DIC. Platelet count (
Choice
A) is decreased in DIC due to consumption, but it is not specific for diagnosing DIC. Prothrombin time (PT -
Choice
B) and partial thromboplastin time (PTT -
Choice
C) are both elevated in DIC because clotting factors have been used up, but they are not specific for DIC as they can be elevated in other conditions as well.

Correct Answer: C

Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms.

Choices A, B, and D are appropriate interventions.
Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety.
Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms.
Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.

Correct Answer: C

Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice
A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice
B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice
D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.

Correct Answer: D

Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.

Correct Answer: A

Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.