NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing may be potential evidence with legal implications.
- B. Such care facilitates the preservation of potential evidence.
- C. The clothing of a trauma victim can be used for further investigation.
- D. Such care maintains the integrity of the clothing for forensic analysis.
Correct answer: The clothing may be potential evidence with legal implications.
Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.
2. 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.
3. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child’s scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct answer: The history and presentation might indicate an infectious illness called impetigo.
Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage. Choice A is incorrect as the presentation is not consistent with chickenpox. Choice B is incorrect because impetigo is contagious, especially through direct contact. Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.
4. What must the evening nurse do to facilitate the client's ECT treatment the next morning?
- A. Ensure the patient signs an informed consent form
- B. Administer evening medications
- C. Ensure the patient gets a good night’s sleep
- D. Provide dietary restrictions as per ECT protocol
Correct answer: Ensure the patient signs an informed consent form
Rationale: For electroconvulsive therapy (ECT) treatment, obtaining informed consent is crucial before the procedure. This ensures the patient is aware of the risks, benefits, and alternatives to the treatment. Administering medications, ensuring rest, and dietary restrictions are important but not directly related to the specific requirement of obtaining informed consent for ECT. The correct answer, ensuring the patient signs an informed consent form, is essential to uphold the patient's autonomy and ensure they have the necessary information to make an informed decision about their treatment.
5. What is the most likely reason for a hospitalized adult client who routinely works from midnight until 8 a.m. to have a temperature of 99.1°F at 4 a.m.?
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct answer: circadian rhythm
Rationale: The correct answer is 'circadian rhythm.' Circadian rhythms are biological cycles that last about 24 hours. The sleep-wake cycle is closely tied to circadian rhythms, affecting body temperature. Normally, core body temperature drops during sleep, reaching its 24-hour low around 4 a.m. In this case, the client's temperature of 99.1°F at 4 a.m. is likely due to the disruption of their circadian rhythm caused by working from midnight until 8 a.m. Choices A, B, and C are incorrect because delta sleep, slow brain waves, and pneumonia do not directly explain the temperature fluctuation based on circadian rhythm.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99