NCLEX Trainer Test 10
Question 1 of 5.
An 8-year-old boy is brought to the physician's office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
A. Grasp the child's hands and ask him to squeeze the nurse's hands.
B. Stroke the plantar surface of the child's foot with a reflex hammer.
C. Gently flex the child's head and neck onto the chest.
D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Explanation: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski's sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski's sign is not indicated, and Romberg's sign assesses balance.
Question 2 of 5.
Extract:A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
C. Help the client obtain a sponsor through a 12-step group in the client's local area.
D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Explanation: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
Question 3 of 5.
Extract:A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
B. I'll use a tongue blade to collect a small amount of stool in a clean container.
C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
D. I'll ask the patient if he has ingested any red meat recently.
Explanation: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
Question 4 of 5.
Extract:A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
A. Determine what other medications the patient is taking.
B. Perform a neurological assessment.
C. Administer haloperidol decanoate (Haldol D) IM stat.
D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Explanation: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane
Question 5 of 5.
Extract:The nurse is caring for patients on the surgical floor and has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.
D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.
Explanation: Strategy: Think ABCs. (1) does not indicate acute bleeding, small amount of blood (2) expected outcome (3) indicates resolution (4) correct-risk for peritonitis, should be assessed for further symptoms of infection
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