NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
- A. “Given time and motivation, your son may regain some function, but I will seek more information from the physician.”
- B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
- C. “I’m not sure, but I’ll call the physician to discuss this with you promptly.”
- D. “It's not beneficial for your son if you get upset.”
Correct answer: “I’m not sure, but I’ll call the physician to discuss this with you promptly.”
Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, “I’m not sure, but I’ll call the physician to discuss this with you promptly,” the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.
2. What is the appropriate intervention for a client who is restrained?
- A. Remove the restraints and provide skin care every hour.
- B. Document the condition of the client’s skin every 3 hours.
- C. Assess the restraint every 30 minutes
- D. Tie the restraint to the side rails.
Correct answer: Assess the restraint every 30 minutes
Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
3. A nurse notes that a client’s physical examination record states that the client’s eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?
- A. Near vision
- B. Central vision
- C. Peripheral vision
- D. Ocular movements
Correct answer: Ocular movements
Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.
4. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
- A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
- B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
- C. I should wait until all my hair falls out to purchase a wig.
- D. I should try to drink 8–10 glasses of water a day.
Correct answer: I should wait until all my hair falls out to purchase a wig.
Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.
5. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?
- A. “You should discuss the inheritance risk with your physician.”
- B. “Sickle cell disease is genetically based and might be passed on to children.”
- C. “Sickle cell disease is genetically based and is not passed on to children.”
- D. “Sickle cell disease is caused by an infection and cannot be passed on to children.”
Correct answer: “Sickle cell disease is genetically based and might be passed on to children.”
Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.
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