NCLEX-PN
NCLEX Physiological Adaptation Questions
Extract:
Question 1 of 5
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
Correct Answer: B
Rationale: Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
Question 2 of 5
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
Correct Answer: D
Rationale: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents' social contacts and teach about community resources.
Question 3 of 5
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
Correct Answer: C
Rationale: The client needs to learn how to communicate directly with his wife about her behavior. The nurse's assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation.
Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn't present.
Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he'll waste precious time convincing the nurse that he or she should do his work.
Question 4 of 5
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
Correct Answer: B
Rationale: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechiae) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.
Question 5 of 5
Social support systems include of the following except:
Correct Answer: D
Rationale: Use of coping skills and verbalization for anger management are personal strategies, not examples of social support systems.
Choices 1, 2, and 3 are all social support systems.