NCLEX Example Questions And Answer 3th Edition

NCLEX Example Questions And Answer 3th Edition

1. A nurse understands that an infant with a diagnosis of hydrocephalus has a head that is heavier than the average infant and that special safety precautions are needed when moving the infant.  Which statement would the nurse include when providing instructions to the parents to reflect this safety need?

A. “When picking up your infant, support the infant’s neck and head with the open palm of your hand.”
B. “Feed your infant in a side-lying position.”
C. “Place a helmet on your infant when in bed.”
D. “Hyperextend your infant’s head with a rolled blanket under the neck area.”

Answer: A. “When picking up your infant, support the infant’s neck and head with the open palm of your hand.”

Rationale: Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system.  This characteristic causes the increase in the weight of the infant’s head.  The infant’s head becomes top heavy.  Supporting the infant’s head and neck when picking it up will prevent hyperextension of the neck area and the infant from falling backwards.  The infant should be fed with the head elevated for proper motility of food processing.  A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant’s head can put pressure on the neck vertebrae causing injury.
Test-Taking Strategy: Focus on the issue—prevention of injury when moving the infant with an enlarged head size. Options 2, 3, and 4 are unsafe practices and, additionally, do not specifically address the issue of the question—moving the infant.  If you had difficulty with this question, review care to the infant with hydrocephalus.

Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 106-107.

2. A nurse is evaluating the parent’s understanding of discharge care regarding the functioning of the infant’s ventricular peritoneal shunt.  Which statement by a parent indicates an understanding of the shunt complications?

A. “If my baby has a high-pitched cry, I should call the doctor.”
B. “I should position my baby on the side with the shunt when sleeping.”
C. “My baby will pass urine more often now that the shunt is in place.”
D. “I should call my doctor if my baby refuses purees.”

Answer: A. “If my baby has a high-pitched cry, I should call the doctor.”

Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity.  The cerebrospinal fluid will build up in the cranial area.  The result is intracranial pressure, which then causes a high-pitched cry in the infant.  The baby should not have pressure placed on the shunt side.  Skin breakdown and possible compression to the apparatus could result.  This type of shunt affects the gastrointestinal system, not the genitourinary system.  Option 4 is only a concern if the baby becomes malnourished or dehydrated, which could then raise the body temperature.  Otherwise, refusal to eat purees has no direct relationship to the shunt functioning.
Test-Taking Strategy: Use the process of elimination. Remember that a high-pitched cry in an infant indicates a concern or problem.  If you had difficulty with this question, review the findings that indicate a complication with a shunt.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 324.

3. A nurse is caring for a newborn with a diagnosis of spina bifida (meningomyelocele). The nurse monitors for a major symptom associated with this disorder when the nurse:

A. Checks the capillary refill on the nail beds of the upper extremities
B. Tests the urine for blood
C. Palpates the abdomen for masses
D. Checks for responses to painful stimuli from the torso downward

Answer: D. Checks for responses to painful stimuli from the torso downward

Rationale: Newborns with spina bifida (meningomyelocele type) demonstrate lack of nerve innervation from below the site of the gibbus (sac containing the meninges and spinal cord).  They therefore show diminished or no responses to painful stimuli in the areas below the gibbus.  Options 1, 2, and 3 are incorrect because the area above the gibbus is not affected.  The capillary refill would be normal.  The urine will not have blood present.  If the kidneys are affected, proteinuria could be present, but this is not generally noted in the newborn period.  No masses are present besides the gibbus on the back area, externally protruding from the vertebral deformity.
Test-Taking Strategy: Note the key words major symptom.  Recalling the anatomical location of spina bifida (meningomyelocele) will direct you to option 4.  If you had difficulty with this question, review these complications.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 107.

4. A nurse is caring for a newborn with spina bifida (meningomyelocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord).  In the preoperative period, the priority nursing action is to monitor:

A. Blood pressure
B. Moisture of the normal saline dressing on the gibbus area
C. Specific gravity of the urine
D. Anterior fontanel for depression

Answer: B. Moisture of the normal saline dressing on the gibbus area

Rationale: The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents.  This prevents tearing or breakdown of the skin integrity at the site.  Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection.  Urine concentration is not well developed in the newborn stage of development.  Depression of the anterior fontanel is a sign of dehydration.  With spina bifida, an increase in intracranial pressure is more of a priority.  A complication of spina bifida would demonstrate a bulging or taut anterior fontanel.
Test-Taking Strategy: Focus on the issue—a preoperative priority nursing action. Blood pressure and specific gravity are common preoperative assessments but are not as reliable an indicator of changes in newborn status as they would be for an older child.  From the remaining options, note the relation between the issue and option 2.  Review preoperative care and newborn development of organs and body functioning if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 108.

5. A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy.  The instructor asks the student about the function of thyroxine.  Which statement by the student indicates an understanding of this hormone?

A. “It softens the muscles and joints of the pelvis.”
B. “It is the primary hormone of milk production.”
C. “It increases during pregnancy to stimulate basal metabolic rate.”
D. “It maintains the uterine lining for implantation.”

Answer: C. “It increases during pregnancy to stimulate basal metabolic rate.”

Rationale: Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis.  Prolactin is the primary hormone of milk production.  Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle including the uterus.
Test-Taking Strategy: Knowledge regarding the function of the various hormones related to pregnancy is needed to answer this question.  Focusing on the name of the hormone “thyroxine” will assist in directing you to option 3.  If you are unfamiliar with these hormones, review this content.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Fundamental Skills
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 366.

Source : NCLEX example quiz and answer

Read also :

• NCLEX RN Quiz Edition 1
• NCLEX Question and Answer Edition 2 (Sub.Child Health)

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