NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: D

Rationale: The correct answer is D: Trochanter. The Greater Trochanter is located on the lateral aspect of the proximal femur and is a large, blunt, irregularly shaped bony process. It serves as an important attachment site for many muscles of the legs, providing leverage and movement.
Choice A, Tubercle, is a small rounded projection, usually for the attachment of a ligament or tendon.
Choice B, Tuberosity, is a large rounded projection, also typically for muscle attachment.
Choice C, Condyle, refers to a rounded articular surface at the end of a bone, usually involved in joints.

Correct Answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

Correct Answer: A

Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk.
Choice A is correct.

Choices B, C, and D are incorrect.
Choice B describes adduction, which is the movement of a body part toward the midline.
Choice C describes wrist rotation, not arm abduction.
Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.

Correct Answer: B

Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.

Correct Answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately.

Choices A, C, and D are incorrect.
Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method.
Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates.
Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.