NCLEX NCLEX-PN
NCLEX Question of The Day
1. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
- A. A three-hour-old just waking up after a period of sleep
- B. A two-day-old crying loudly
- C. A three-day-old two hours after circumcision
- D. A one-hour-old sucking his fist
Correct answer: A three-hour-old just waking up after a period of sleep
Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.
2. A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, 'We were stunned when we learned that our son had schizophrenia. He was no different from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication.' Which response by the nurse is appropriate?
- A. Telling the parents, 'Medication noncompliance is the most frequent reason that people with this diagnosis relapse.'
- B. Telling the parents, 'Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication.'
- C. Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'
- D. 'Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.'
Correct answer: Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'
Rationale: The appropriate response is to ask the client how they can be helped in taking their medication or sharing problems to adjust the medication. This approach promotes direct communication with the client, allowing for better assessment of the situation and understanding the client's motivations and behaviors. It also encourages openness and mutual communication between the client and their family. Choice A provides important information about noncompliance as a common reason for relapse but lacks a therapeutic approach by not facilitating emotional expression. Choice B uses a threatening message and is nontherapeutic. Choice D prematurely analyzes the client's motivations without sufficient assessment and lacks a therapeutic communication style.
3. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved.
Correct answer: Grimacing and writhing movements decrease with relaxation and rest.
Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.
4. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalohematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct answer: A cephalohematoma
Rationale: The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.
5. Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct answer: eggs
Rationale: The correct answer is 'eggs.' Eggs are considered a complete protein as they contain all nine essential amino acids required by the body. On the other hand, corn, peanuts, and sunflower seeds are incomplete proteins, meaning they lack one or more of the essential amino acids needed by the body for optimal health. Corn, peanuts, and sunflower seeds are plant-based proteins that are deficient in one or more essential amino acids, unlike eggs, which are a high-quality complete protein source.
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