a two year old child has sustained an injury to the leg and refuses to walk the nurse in the emergency department documents swelling of the lower affe
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Questions

1. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?

Correct answer: A

Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb. Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk. Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk. Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.

2. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.

Correct answer: D

Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.

3. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

Correct answer: D

Rationale: During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.

4. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize:

Correct answer: B

Rationale: The correct answer is administration of thyroid hormone will prevent problems. In newborns diagnosed with hypothyroidism, early identification and continuous treatment with hormone replacement can correct this condition effectively. Choice A is incorrect as it uses outdated and inappropriate language (mentally retarded) and does not reflect modern understanding of conditions. Choice C is incorrect because while some cases of hypothyroidism can be hereditary, it is not always the case. Choice D is incorrect as physical growth and development can be affected by hypothyroidism, but the critical emphasis should be on the importance of administering thyroid hormone to prevent complications and support normal growth and development.

5. A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

Correct answer: C

Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.

Similar Questions

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
To palpate the liver during a head-to-toe physical assessment, the nurse should
While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses