the nurse is assessing the mental status of a client admitted with possible organic brain disorder which of these questions will best assess the funct
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NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. The healthcare provider is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?

Correct answer: B

Rationale: The correct answer is to ask the client to perform a calculation that involves working memory and processing skills. This question not only assesses the recent memory but also evaluates attention and executive functioning. The choice 'I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen' assesses immediate recall rather than recent memory. Asking about the current year or season tests orientation rather than recent memory. Inquiring about the watch and its purpose assesses comprehension and judgment rather than recent memory.

2. A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse's priority action?

Correct answer: D

Rationale: Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would lead to decreased urine output. This is a serious adverse effect that should be promptly reported to the physician. Checking the patient's last BUN levels (Choice A) may provide additional information but does not address the urgency of the situation. Asking the patient to increase fluid intake (Choice B) may not be appropriate if the cause is related to Vancomycin toxicity. Ordering a diuretic (Choice C) without physician evaluation can exacerbate the issue, making notifying the physician (Choice D) the most critical action to take.

3. Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

Correct answer: D

Rationale: The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.

4. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

Correct answer: B

Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.

5. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?

Correct answer: A

Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.

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