NCLEX NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.
- A. Regular developmental screening is important to avoid secondary developmental delays.
- B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
- D. Parent support groups are helpful for sharing strategies and managing health care issues.
Correct answer: Developmental milestones may be slightly delayed but usually will require no additional intervention.
Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child’s growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.
2. When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?
- A. Palpate over the area for increased pain and tenderness.
- B. Ask the child to take shallow breaths and percuss over the area again.
- C. Refer the child to a specialist because of an increased amount of air in the lungs.
- D. Consider this finding as normal for a child this age and proceed with the examination.
Correct answer: Consider this finding as normal for a child this age and proceed with the examination.
Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.
3. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
- A. Ask the patient to lie down to complete a full physical assessment.
- B. Briefly ask specific questions about this episode of respiratory distress.
- C. Complete the admission database to check for allergies before treatment.
- D. Delay the physical assessment to first complete pulmonary function tests.
Correct answer: Briefly ask specific questions about this episode of respiratory distress.
Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
4. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- A. Document the seizure
- B. Perform neurologic checks
- C. Take the patient’s vital signs
- D. Restrain the patient for protection
Correct answer: Take the patient’s vital signs
Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.
5. How can the dangers associated with wandering in Alzheimer's disease patients be prevented?
- A. Bed alarms
- B. Chair alarms
- C. Door alarms
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' Bed alarms, chair alarms, and door alarms are all effective measures to prevent the dangers associated with wandering in Alzheimer's disease patients. These alarms can alert caregivers when a patient tries to leave a designated area, helping to keep them safe. It is crucial to respond promptly to these alarms to ensure the patient's safety. Choices A, B, and C are incorrect individually as each type of alarm plays a vital role in a comprehensive wandering prevention strategy.
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