the nurse is assessing a 3 year old child for symptoms of autism spectrum disorder asdwhich assessment finding should lead the nurse to question the d

NCLEX-RN

NCLEX RN Exam Review Answers

1. The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?

A. Inability to react appropriately to social cues
B. Engages in repetitive behaviors
C. Comprehends language well beyond the complexity expected for age
D. Displays self-destructive behavior

Correct answer: C

Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.

2. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?

A. A 26-year-old woman who had a bowel resection
B. A 40-year-old man who underwent a hernia repair
C. A 31-year-old woman with septicemia and who is on a ventilator
D. A 91-year-old man with Alzheimer's disease recovering from a fall

Correct answer: A

Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.

3. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Correct answer: D

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

4. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:

A. Respiratory protection must be provided to all employees who might be exposed.
B. Training on respiratory protection must be provided.
C. Employers must provide personal protective equipment to all employees.
D. All ED personnel must be trained in decontamination procedures.

Correct answer: D

Rationale: OSHA regulations for hospital employees dealing with hazardous materials or exposed patients require respiratory protection for potentially exposed employees, training on respiratory protection, and the provision of personal protective equipment. However, not all ED personnel are required to be trained in decontamination procedures. While all ED staff should have a basic understanding of hazmat situations, specific training in decontamination procedures is only necessary for those who will be directly involved in the decontamination process. Therefore, the correct answer is that all ED personnel must be trained in decontamination procedures, as this is not a mandatory requirement under OSHA regulations for hospital employees who may encounter hazardous materials or exposed patients.

5. Which of the following is an example of intragroup conflict?

A. A nurse writes a grant for a non-profit organization to raise money for advertising
B. Members of a multidisciplinary team cannot agree on the best course of action for a client
C. A client does not receive his medication on time because the nurse was on break
D. A nurse feels frustrated that her employer does not provide on-site child care

Correct answer: B

Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.