NCLEX-RN
NCLEX RN Exam Prep
1. What term is used to refer to generalized wasting of body tissues and malnutrition?
- A. Entropion
- B. Confabulation
- C. Induration
- D. Cachexia
Correct answer: D
Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.
2. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
- A. Blood pressure guidelines for children are based on age.
- B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
- C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
- D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Correct answer: D
Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.
3. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?
- A. Pull out that page of the chart and rewrite it with the correct information.
- B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
- C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
- D. All of the above are incorrect.
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.
4. What message is a patient sending when displaying the following body language: Slumped shoulders, grimace, and stiff joints?
- A. Anger
- B. Aloofness
- C. Empathy
- D. Depression
Correct answer: A
Rationale: Body language is a powerful form of non-verbal communication that can convey various emotions. In this scenario, the patient's slumped shoulders, grimace, and stiff joints suggest a negative emotional state. Anger is the correct answer because grimacing and tense posture are commonly associated with anger. Choice B, 'Aloofness,' is incorrect as aloofness is more related to disinterest or detachment, which is not indicated by the described body language. Choice C, 'Empathy,' is incorrect as the body language described does not align with expressing understanding or compassion towards others. Choice D, 'Depression,' is incorrect as while depression can also manifest through body language, the specific cues given in the scenario lean more towards anger than depression.
5. When caring for children with a different cultural perspective, what challenge may the nurse recognize?
- A. Children have spiritual needs that are influenced by their stages of development
- B. Children have spiritual needs that are direct reflections of what is occurring in their homes
- C. Religious beliefs rarely affect the parents' perceptions of the illness
- D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs
Correct answer: A
Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.
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