NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 211:

  A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

  A. Crying

  B. Falling asleep

  C. Rolling from his back to his tummy

  D. Sucking his thumb

  Correct Answer: A

  (A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.

• Question 212:

  A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:

  A. Mild hypotonia is expected in the upper extremities.

  B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.

  C. Function progresses in a head-to-toe, proximal-distal fashion.

  D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.

  Correct Answer: C

  (A) Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. (B) Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. (C) Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. (D) Asymmetrical movements of the extremities are indicative of neurological dysfunction.

• Question 213:

  A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

  A. Encourage him to drink plenty of fluids

  B. Expect him to have nausea with vomiting

  C. Keep him awake for the next 12 hours

  D. Wake him up every 1? hours during the night

  Correct Answer: D

  (A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C) The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

• Question 214:

  A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

  A. Assess level of consciousness

  B. Assess suicide potential

  C. Observe for sedation and hypotension

  D. Orient to her room and unit rules

  Correct Answer: B

  (A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if comatose. (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicide assessment. (D) Orientation to room and unit rules is of low priority at this time.

• Question 215:

  A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:

  A. An increased risk in maternal adaptation to pregnancy

  B. The need for anticipatory guidance regarding the pregnancy

  C. The need for teaching regarding family planning

  D. An increased risk for subsequent abortions

  Correct Answer: B

  (A, D) There are no data to support this. (B) Anticipatory guidance and health maintenance is a first-line defense in the promotion of healthy mothers and healthy babies. (C) There are no data to support this at this time. This will be a concern later.

• Question 216:

  A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

  A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group."

  B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA."

  C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with my divorce."

  D. "It really wasn't my fault that I had to come here. If my wife hadn't left, I wouldn't have needed those drinks."

  Correct Answer: A

  (A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him--Alcoholics Anonymous. (B) The client is still using denial and is not dealing with his alcohol addiction. (C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce. (D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction.

• Question 217:

  Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?

  A. "Some folks believe that aging causes this, Mother."

  B. "Perhaps, it's the way your parents used those double- bind messages, Mother."

  C. "I know some people who are having this problem and they were exposed to chemicals at work, Mother."

  D. "It can be caused by lots of things, toxic agents and even alcohol, Mother."

  Correct Answer: B

  (A) Aging is a factor in the cause of degenerative disorders. (B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to degenerative disorders. (C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders. (D) Alcohol causes some degenerative disorders, such as Wernicke's syndrome.

• Question 218:

  A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

  A. "I don't see your mother in the room. Let's talk about how you're feeling."

  B. "OK, I'll come back later when you're feeling more like taking your medicine."

  C. "She may be here, but I can't see her."

  D. "Why don't you finish talking to her, and I'll wait."

  Correct Answer: A

  (A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.

• Question 219:

  Before giving methergine postpartum, the nurse should assess the client for:

  A. Decreased amount of lochial flow

  B. Elevated blood pressure

  C. Flushing

  D. Afterpains

  Correct Answer: B

  (A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.

• Question 220:

  Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?

  A. "You may resume sexual intercourse in 2 weeks."

  B. "Many men experience impotence following TURP."

  C. "A transurethral resection does not usually cause impotence."

  D. "Check with your doctor about resuming sexual activity."

  Correct Answer: C

  (A) Sexual activity should be delayed until cleared by the client's physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety.