the atlas and the axis

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. The Atlas and the Axis are:

A. found in the vertebrae.
B. described as being cervical.
C. the first two bones that form the column for the spine on the superior aspect.
D. All of the above.

Correct answer: D

Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.

2. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

A. After menopause, blood pressure readings in women are usually higher than those taken in men.
B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
D. A teenager's blood pressure reading may be lower than that of an adult.

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

3. Match the abbreviation with the correct definition:

A. bid: twice a day
B. tid: three times a day
C. ac: before meals
D. pc: after meals

Correct answer: C

Rationale: The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.

4. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

A. Restrain the client in bed
B. Ask a family member to stay with the client
C. Check the client every 15 minutes
D. Use a bed exit safety monitoring device

Correct answer: D

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

5. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulates in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief

Correct answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.