Test Prep NCLEX-PN Exam Practice Questions (P. 2)
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Question #11
A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- Aadministering immune globulin intravenously
- Bassessing the extremities for edema, redness and desquamation every 8 hours
- Cexplaining progression of the disease to the client and his or her family
- Dassessing heart sounds and rhythm
Correct Answer:
C
Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease. Health Promotion and Maintenance
C
Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease. Health Promotion and Maintenance
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Question #12
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- Aimmobility
- Baltered growth and development
- Chemarthrosis
- Daltered family processes
Correct Answer:
D
Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infants development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client.
Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac. Health Promotion and Maintenance
D
Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infants development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client.
Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac. Health Promotion and Maintenance
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Question #13
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A"I will assist you in arranging to have a medicine woman present."
- B"We do not allow medicine women in exam rooms."
- C"That does not make any difference in the outcome."
- D"It is old-fashioned to believe in that."
Correct Answer:
A
This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional. Reduction of Risk Potential
A
This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional. Reduction of Risk Potential
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Question #14
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- Aincrease maternal fluids.
- Badminister oxygen.
- Cdecrease maternal fluids.
- Dturn the mother.
Correct Answer:
C
Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated. Reduction of Risk Potential
C
Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated. Reduction of Risk Potential
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Question #15
Which fetal heart monitor pattern can indicate cord compression?
- Avariable decelerations
- Bearly decelerations
- Cbradycardia
- Dtachycardia
Correct Answer:
A
Variable decelerations can be related to cord compression. The other patterns are not. Reduction of Risk Potential
A
Variable decelerations can be related to cord compression. The other patterns are not. Reduction of Risk Potential
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Question #16
Which of the following conditions is mammography used to detect?
- Apain
- Btumor
- Cedema
- Depilepsy
Correct Answer:
B
Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential
B
Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential
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Question #17
Why might breast implants interfere with mammography?
- AThey might cause additional discomfort.
- BThey are contraindications to mammography.
- CThey are likely to be dislodged.
- DThey might prevent detection of masses.
Correct Answer:
D
Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography. Reduction of Risk
Potential
D
Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography. Reduction of Risk
Potential
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Question #18
Which of the following instructions should the nurse give a client who will be undergoing mammography?
- ABe sure to use underarm deodorant.
- BDo not use underarm deodorant.
- CDo not eat or drink after midnight.
- DHave a friend drive you home.
Correct Answer:
B
Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home. Reduction of Risk Potential
B
Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home. Reduction of Risk Potential
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Question #19
Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding?
- Ametastatic liver cancer
- Bgram-negative septicemia
- Cpernicious anemia
- Diron-deficiency anemia
Correct Answer:
C
Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption.
The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support. Physiological
Adaptation
C
Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption.
The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support. Physiological
Adaptation
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Question #20
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?
- Aincreased platelet count
- Bincreased fibrinogen
- Cdecreased fibrin split products
- Ddecreased bleeding
Correct Answer:
B
Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors. Physiological
Adaptation
B
Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors. Physiological
Adaptation
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