NCLEX-PN
Nclex Questions Management of Care
1. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. pureed canned squash
- B. pureed apples
- C. yogurt
- D. infant rice cereal
Correct answer: D: infant rice cereal
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.
2. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
- A. Native American
- B. Asian-Pacific
- C. Norwegian
- D. Hispanic
Correct answer: Hispanic
Rationale: The correct answer is 'Hispanic.' Hispanic individuals in the United States are at a higher risk for pesticide-related injuries due to their representation among migrant workers in agricultural settings. This exposure to pesticides in their work environments increases their risk compared to other ethnic groups. Choice A, 'Native American,' although indigenous populations may face environmental health disparities, the higher risk in this context is among Hispanic individuals. Choice B, 'Asian-Pacific,' and Choice C, 'Norwegian,' do not have the same level of exposure to pesticides as Hispanic migrant workers, making them less susceptible to pesticide-related injuries.
3. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct answer: Consider it a normal finding.
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
4. Which of the following syndromes associated with incomplete lesions of the spinal cord results from damage to one-half of the spinal cord?
- A. Brown-Séquard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct answer: Brown-Séquard syndrome
Rationale: Brown-Séquard syndrome is indeed associated with incomplete lesions of the spinal cord, and it specifically results from damage to one-half of the spinal cord. This syndrome manifests as ipsilateral motor paralysis, ipsilateral loss of vibration and proprioception, and contralateral loss of pain and temperature sensation. Posterior cord syndrome mainly involves the loss of proprioception and vibratory sense, while sparing motor function and pain sensation. Central cord syndrome typically presents with more weakness in the upper extremities compared to the lower extremities due to central spinal cord damage. Cauda equina syndrome affects the nerve roots at the level of the conus medullaris, leading to symptoms like lower extremity weakness, numbness, and bowel/bladder dysfunction.
5. Which of the following is least important to test when assessing the client’s motor skills?
- A. strength
- B. knowledge of ergonomics
- C. balance
- D. coordination
Correct answer: B
Rationale: When assessing a client’s motor skills, it is crucial to evaluate their strength, balance, and coordination as these directly impact their motor abilities. Strength is essential to perform tasks, balance is required for stability, and coordination is necessary for smooth movements. However, knowledge of ergonomics, while beneficial for overall understanding, is not directly related to assessing motor skills. The focus should be on physical abilities rather than theoretical knowledge of ergonomics. Therefore, testing the client’s knowledge of ergonomics is the least important when evaluating their motor skills.
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