NCLEX NCLEX-PN
NCLEX PN Test Bank
1. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct answer: The disorder is uncommon in adults.
Rationale: The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.
2. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct answer: promote healthy nutritional practices
Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.
3. A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions.
- B. making a baseline record of the time the wife spends cleaning.
- C. decreasing the stimuli in the home.
- D. helping his wife with the cleaning.
Correct answer: decreasing the stimuli in the home.
Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.
4. Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing’s advocacy for clients.
- C. confidentiality.
- D. health care.
Correct answer: nursing’s advocacy for clients.
Rationale: Client self-determination is the primary focus of nursing’s advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.
5. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?
- A. The fingers curl tightly, and the toes curl forward.
- B. The toes flare, and the big toe is dorsiflexed.
- C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
- D. The infant turns to the side that is touched.
Correct answer: The toes flare, and the big toe is dorsiflexed.
Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.
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