NCLEX-PN
NCLEX PN Practice Questions Quizlet
1. An appraisal of self-care practices involves an assessment of:
- A. all diagnostic tests.
- B. home treatment practices, including nurse visits for the sick or disabled.
- C. the family's capability to get health insurance.
- D. caregiving needs and the potential for strain.
Correct answer: D
Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.
2. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?
- A. Assessing visual acuity
- B. Inspecting the eyelids for ptosis
- C. Assessing pupil constriction
- D. Assessing ocular movements
Correct answer: A
Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.
3. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?
- A. Inform the staff on the other floor of any unresolved issues with the client.
- B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
- C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information, and a report should not be needed.
- D. Complete the transfer paperwork before the client is transferred.
Correct answer: C
Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.
4. A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?
- A. Smiling
- B. Clenching the teeth
- C. Shrugging the shoulders against the nurse's resistance
- D. Identifying by taste a substance placed on the back of the tongue
Correct answer: C
Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.
5. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
- A. measles, polio, pertussis, hepatitis B
- B. diphtheria, pertussis, polio, tetanus
- C. rubella, polio, pertussis, hepatitis A
- D. measles, mumps, rubella, polio
Correct answer: B
Rationale: By 12 months of age, children should have received the DTaP (diphtheria, pertussis, and tetanus) vaccine along with the polio vaccine. The MMR (measles, mumps, and rubella) vaccine is not typically given until the child is 12-15 months old. Therefore, option B is correct as it includes vaccines that are usually administered by 12 months of age. Options A, C, and D are incorrect as they include vaccines that are typically given after 12 months of age.
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