Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16-weeks gestation. Which of the following actions will the nurse take before the procedure to ensure the maintenance of fetal safety during the procedure?
A. Require that the client empty her bladder
B. Test the ultrasound equipment to assure proper functioning
C. Teach the client the signs and symptoms of labor
D. Prepare a local anesthetic to be used during the insertion of the spinal needle
Answer: B. Test the ultrasound equipment to assure proper functioning
Rationale: Before 20 weeks of gestation, it is recommended to perform an amniocentesis with the bladder full. This pushes the uterus upward for better visualization. After week 20, the bladder is emptied before the test to minimize the risk of puncturing the bladder during the test. The client does need to be taught about the signs and symptoms of labor because this action does not ensure fetal safety. The local anesthetic makes the insertion of the needle less painful but does not protect the fetus. The use of ultrasound to guide the procedure has greatly decreased the risk of fetal and placental damage during the procedure.
Test-Taking Strategy: Focus on the issue of the question—ensure the maintenance of fetal safety during the procedure. Note the key words during the procedure and 16-weeks gestation to assist in answering the question. Review preparation for amniocentesis if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 69.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 330.
2. A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband knowing that which of the following will assist to promote family adaptation?
A. Teaching the husband to administer and titrate tocolytic agents
B. Teaching the husband to instruct the wife how to perform Kegel exercises
C. Teaching the husband to perform passive range of motion exercises and provide backrubs for his wife
D. Telling the husband that sexual intercourse has probably caused the preterm labor
Answer: C. Teaching the husband to perform passive range of motion exercises and provide backrubs for his wife
Rationale: Range of motion exercises will help maintain muscle tone during bed rest, and back rubs provide skin-to-skin contact and are comforting. The inclusion of the significant other promotes adaptation and decreases the sense of isolation. Option 4 will lead to guilt and lead to maladaptation. The husband should not be expected to titrate medications. Kegel exercises are beneficial but will not provide the human-to-human contact that promotes family adaptation.
Test-Taking Strategy: Focus on the issue—promoting family adaptation. Option 3 is the only option that identifies human-to-human contact that will promote family adaptation. Review the psychosocial aspects related to pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 690-691.
3. A client of the age of 23 develops melasma during pregnancy. The nurse notes that the client has started wearing very heavy makeup. The client tells the nurse that she is fearful that her mate will reject her, and that she has decreased her social engagements drastically because of this change. The nurse determines that the client is experiencing which problem?
A. Body image disturbance
B. Anxiety
C. Social isolation
D. Altered role performance
Answer: A. Body image disturbance
Rationale: Although the nurse might consider all of these problems initially, the information described in the question most clearly relates to body image disturbance. Anxiety is inaccurate because there is a physical focus for the problem—melasma. The client has decreased social engagements, but there is no indication that she has excluded all activities. There are insufficient data to support altered role performance.
Test-Taking Strategy: Use the process of elimination, focusing on the information provided in the question. This will assist in directing you to option A. Review the effect of melasma if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 257.
4. A nurse employed in a physician’s office is collecting information from a pregnant client. Which of the following statements made by the client most likely indicates the need for psychological referral?
A. “I will never be able to lose my weight and regain a great figure. I feel ugly.”
B. “I don’t like the way I look. My husband could never find me attractive again.”
C. “I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant.”
D. “I have terrible mood swings. I will be glad when this is all over.”
Answer: C. “I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant.”
Rationale: Options 1, 2, and 4 are feelings about self and body image that many women express during pregnancy. The statement in option 3 is much stronger and places blame on the fetus. The direction of anger to the fetus should be explored. The nurse may find that a psychological referral is appropriate.
Test-Taking Strategy: Use the process of elimination. Note the key words hate and baby has done this to me in the correct option. Review normal and abnormal psychological responses to pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 690-691.
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