the clinic nurse asks a 13 year old female to bend forward at the waist with arms hanging freely which of the following assessments is the nurse most

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A. Spinal flexibility
B. Leg length disparity
C. Hypostatic blood pressure
D. Scoliosis

Correct answer: D

Rationale: The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.

2. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?

A. Call a family member to interpret
B. Consult the hospital translator to assist
C. Allow the consent to be signed
D. Ask the staff member to come back later

Correct answer: B

Rationale: Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.

3. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?

A. Palpating the temperature of both feet
B. Evaluating pulses bilaterally
C. Turning the client to a side-lying position
D. Relieving heel pressure by placing a pillow under the foot

Correct answer: C

Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.

4. Which of the following is an example of intrapersonal conflict?

A. A nurse feels guilty when she administers essential medication that causes a client to have nausea and vomiting
B. A nurse is called to testify in court about a client she cared for three years ago
C. A nurse feels guilty for working overtime
D. A nurse faces a conflict with a colleague over patient care decisions

Correct answer: A

Rationale: Intrapersonal conflict involves negative feelings or frustrations within oneself. It may be related to decisions or actions that clash with personal morals or beliefs. Choice A is the correct answer because the nurse is experiencing guilt due to administering medication that causes a client to have negative side effects, which reflects an internal struggle. Choices B, C, and D do not represent intrapersonal conflict. Choice B involves a legal obligation, Choice C is related to external factors like working overtime, and Choice D pertains to a conflict with a colleague.

5. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

A. The patient had a blood transfusion in 2005
B. The patient used IV drugs about 20 years ago
C. The patient frequently eats in fast-food restaurants
D. The patient traveled to a country with poor sanitation

Correct answer: B

Rationale: The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.