Nclex questions for last MC exam!!!

Nclex questions for last MC exam!!!

5.0 (5 reviews) Students also studied Terms in this set (34) Science MedicinePaediatrics Save Cerebral Palsy MNL/NCLEX 46 terms sknewell1Preview Chapter 14 NCLEX questions 32 terms brennaleestuard Preview

Exam 1: Spina Bifida Questions

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Exam 1:

14 terms dan The nurse assesses a child and finds that the child's pupils are pinpoint. The nurse interprets this finding as indicating which of the following?

• intracranial mass
• brain stem dysfunction
• seizure activity
• brain stem herniation
• brain stem dysfunction

Rationale: Pinpoint pupils are commonly observed in poisonings, brain stem

dysfunction, and opiate use. Dilated but reactive pupils are seen after seizures.Fixed and dilated pupils are associated with brain stem herniation. A single dilated but reactive pupil is associated with an intracranial mass.The nurse is providing education to the parents of a 2- year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught?

• "limit the amount of t.v. he watches"
• "watch for changes in his behavior or eating patterns"
• "call the doctor if he gets a headache."
• "always keep his head raised 30 degrees"
• "watch for changes in his behavior or eating patterns"

rationale: Changes in behavior or in eating patterns can suggest a problem with

his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk.What would be the nurse's best intervention in this case?

Select one:

• Ask the parents if they have changed the child's

schedule to a less active one.

• Schedule a full evaluation since this may indicate a

neurologic disorder.

• Note the regression in the child's chart and recheck in

another month.

• Document the findings as a developmental delay since

this is a normal occurrence.

The correct answer is: Schedule a full evaluation since this may indicate a

neurologic disorder.Rationale: Any child who "loses" a developmental milestone—for example, the child able to sit without support who now cannot—needs an immediate full evaluation, since this indicates a significant neurologic problem.

Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis?

Select one:

• Swimming
• Playing basketball
• Jogging every other day
• Using a treadmill
• Swimming

Rationale: Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. Jogging, using a treadmill, and playing basketball would place pressure on the joints of the lower extremities.A nurse is caring for a hospitalized 3 month old infant admitted following a motor vehicle accident. The child is being monitored for increased intracranial pressure. The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action would the nurse take?

Select one:

• Lower the head of the bed
• Have the mother provide comfort measures and

reassess.

• Place the infant on NPO status
• Notify the physician immediately
• Have the mother provide comfort measures and reassess.

Rationale: When an infant cries intercranial pressure increases causing the

fontanel to bulge. Since crying can occur because of hunger, thirst, pain, the nurse should attempt to decrease the crying by assessing the cause. Notifying the MD first would result in the MD asking the question, "What have you done to decrease the cause of the cry which is increasing the icp?The nurse suspects that a 4-year-old with type 1 diabetes is experiencing hypoglycemia based on which of the following? Select all that apply.

Select one or more:

• Diaphoresis
• Blurred vision
• Fruity breath odor
• Slurred speech
• Tachycardia
• Dry, flushed skin

The correct answer is: Diaphoresis, Slurred speech, Tachycardia

Rationale: Manifestations of hypoglycemia include behavioral changes, confusion, slurred speech, belligerence, diaphoresis, tremors, palpitation, and tachycardia.Blurred vision; dry, flushed skin; and fruity breath odor suggest hyperglycemia.The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse knows that parents need further teaching when they

state:

Select one:

• "We'll watch for any swelling of the feet while the casts

are on."

• "We're happy this is the only cast our baby will need."
• "We'll keep the casts dry."
• "We're getting a special car seat to accommodate the

casts."

• "We're happy this is the only cast our baby will need."

A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see?

Select one or more:

• Bulging fontanel
• Positive Babinski sign
• Vomiting
• Loss of coordination or balance
• Redness along the shunt tract
• Vomiting

Vomiting is a sign of increased intracranial pressure, which is often present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection.

• Loss of coordination or balance

Loss of coordination or balance is a sign of increased intracranial pressure, which may be present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection.

• Redness along the shunt tract

Redness along the shunt tract is often present with a shunt infection as a result of the body's response to the infectious agent.A nurse is doing a postop assessment on an infant who has just had a ventroperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt?

Select one:

• Bulging fontanelle
• Negative Brudzinski sign
• Incisional pain
• Movement of all extremities
• Bulging fontanelle

A lumbar puncture is done on an infant suspected to have meningitis. If the infant has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show what result?

Select one:

• An elevated red blood cell count
• A decreased white blood cell count
• Normal glucose
• An elevated white blood cell count
• An elevated white blood cell count

A child with growth hormone deficiency is receiving growth hormone. Which of the following would the nurse interpret as indicating effectiveness of this therapy?

Select one:

• Rapid weight gain
• Complaints of headaches
• Height increase of 4 inches
• Growth plate closure
• Height increase of 4 inches

Rationale: Effectiveness of growth hormone therapy is indicated by at least a 3- to 5-inch increase in linear growth in the first year of treatment. Rapid weight gain and headaches are adverse reactions of this therapy. The drug is stopped when the epiphyseal growth plates close.A 2-year-old has a tonic-clonic seizure while in the hospital crib. The child's jaws are clamped. Which is the most important nursing action at this time?

Select one:

• Place a padded tongue blade between the child's jaws.
• Restrain the child to prevent injury.
• Prepare the suction equipment.
• Stay with the child and observe his respiratory status.
• Stay with the child and observe his respiratory status.

Rationale: It is important for the nurse to stay with the child to assess for any changes in the child's respiratory status. Place the child in side-lying position, if possible, to allow secretions to drain. Monitor for adequate oxygenation. The child is at risk for hypoxic injury if the respiratory status is compromised.

An infant has been diagnosed with Osteogenesis Imperfecta. (OI). The nurse is teaching the parents about how to care for their infant. What information is most important for the nurse to include in the instructions to the parents?

Select one:

• Notify the health-care provider if your infant does not

respond to sound because the infant's central nervous system fails to develop completely.

• If you note signs of infection bring your infant to the

clinic because the infant has a significant immune dysfunction.

• Protect your infant from injury and handle your baby

carefully because your infant's bones can break very easily

• Check the color of your infant's nail beds and mucous

membranes for the signs of circulatory impairment

• Protect your infant from injury and handle your baby carefully because your

infant's bones can break very easily

Rationale: OI is also known as brittle bone disease and the infant should be

handled carefully and protected from injury.A nurse is teaching the parents of an infant with congenital adrenal hyperplasia about the signs and symptoms of adrenal crisis. The nurse determines that the teaching was successful when the parents identify which of the following?

Select one:

• Persistent vomiting
• Fluid overload
• Constipation
• Bradycardia
• Persistent vomiting

Rationale: Signs and symptoms of acute adrenal crisis include persistent vomiting, dehydration, hyponatremia, hyperkalemia, hypotension, tachycardia, and shock.A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which of the following?

Select one:

• Syndrome of inappropriate antidiuretic hormone

(SIADH)

• Cushing syndrome
• Thyroid storm
• Vitamin D toxicity
• Syndrome of inappropriate antidiuretic hormone (SIADH)

Rationale: SIADH, although rare in children, is a potential complication of

excessive administration of vasopressin. Thyroid storm may result from overadministration of levothyroxine (thyroid hormone replacement). Cushing syndrome is associated with corticosteroid use. Vitamin D toxicity may result from the use of vitamin D as treatment of hypoparathyroidism.An 8-year-old boy with Duchenne muscular dystrophy is being seen in the clinic for a routine health visit. An

appropriate nursing diagnosis for this client would be:

Select one:

• Risk for injury related to muscle weakness.
• Risk for impaired skin integrity related to paresthesia to

lower extremities.

• Risk for infection related to altered immune system.
• Risk for altered comfort related to effects of muscular

dystrophy disease.

• Risk for injury related to muscle weakness.