NCLEX : Patient-Specific Care

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #11 : Pediatric Care And Development

The nurse cares for a 2-year-old boy whose mother is worried that he is not fully toilet trained yet. The mother is worried because he is not yet able to hold his urine for more than a couple hours, but is proud that he can use the toilet for bowel movements. How should the nurse reply to the mother?

Possible Answers:

“Your child could be developmentally delayed and should have achieved full toilet training by now. Let me refer you to a pediatric psychologist.”

“Bladder control is usually achieved before bowel control, but he is on track to become fully potty trained.”

“Bladder control is usually achieved after bowel control, but he should be fully potty trained by this age.”

“You should tell your son ‘no’ every time he wets himself. That is the only way he will learn that his behavior is not acceptable.”

“Bladder control is usually achieved after bowel control, so toilet training can take anywhere from 2 to 3 years to fully achieve.”

Correct answer:

“Bladder control is usually achieved after bowel control, so toilet training can take anywhere from 2 to 3 years to fully achieve.”

Explanation:

Toilet training may be achieved anywhere from 24 months to 36 months, and may sometimes take longer for boys than girls. Bladder control usually occurs after bowel control. Parents should not be concerned if their children take the full 36 months to become toilet trained or if they have difficulty holding their urine longer than a few hours due to the small size of their bladders. Toilet training that takes longer than 3 years may be caused by psychological factors, but this child is not in need of the assessment of a child psychologist at his age. The nurse should not encourage the mother to tell the child that his behavior is unacceptable because it is not expected of him to achieve full toilet training for another year.

Example Question #86 : Procedures And Care

At what age should an infant show stranger anxiety?

Possible Answers:

8-12 months

6-8 months

4-6 months

2-4 months

Correct answer:

8-12 months

Explanation:

An infant begins to show signs of anxiety toward strangers between 8 and 12 months of age and may recur until two years of age. This anxiety can show as silence, staring, writhing or crying in the presence of people they don't know. 

Example Question #87 : Procedures And Care

At what age does an infant develop the grasping response?

Possible Answers:

0-3 months

6-8 months

3-4 months

4-6 months

Correct answer:

0-3 months

Explanation:

The grasping reflex is the earliest reflex developed by the infant. It is often present at birth: the infant will grasp at objects such as a finger placed into their open palm.  

Example Question #751 : Nclex

At what age will an infant develop an inferior pincer grasp?

Possible Answers:

4-5 months

2-4 months

6-9 months

9-12 months

Correct answer:

6-9 months

Explanation:

The inferior pincer grasp is the ability to pick up small objects such as by resting the forearm on a surface and pinching using the sides of the thumb and the index finger. It is an important milestone in the development of fine motor skills.

Example Question #752 : Nclex

Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of what?

 

Possible Answers:

Postpartum psychosis

Postpartum depression

Postpartum anxiety

All of these answers are correct

Correct answer:

Postpartum depression

Explanation:

Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of postpartum depression, a condition that affects as many as four out of five people after giving birth. Postpartum psychosis is a much more serious condition, involving delusions, extreme mood swings, and risk of self harm. 

Example Question #1 : Infant And Postpartum Care

What is the cause of postpartum depression?

Possible Answers:

Social stress

An extreme drop in hormone levels

Lack of sleep

Specific vitamin deficiencies

Correct answer:

An extreme drop in hormone levels

Explanation:

While vitamin deficiencies, lack of sleep, and social stresses can all contribute to depressed mood after giving birth, the primary cause of postpartum depression is an extreme drop in hormones (primarily estrogen and progesterone) that occurs after delivery of the placenta. 

Example Question #11 : Patient Specific Care

A first time mother comes in ten days after giving birth to a healthy daughter. She is concerned because she has been bleeding continuously from her vagina since labor. The blood is red to brown, and she has been using sanitary napkins, which she must change about every 3 hours. How do you counsel her?

Possible Answers:

This is normal bleeding as she expels the remains of the content of her uterus after labor

This is normal bleeding most likely due to the sudden drop in her progesterone levels

This bleeding is abnormal and may be signs of a mild uterine tear

This is an emergency; refer to urgent care

Correct answer:

This is normal bleeding as she expels the remains of the content of her uterus after labor

Explanation:

Postpartum bleeding, referred to as lochia, is a normal process wherein the individual sheds blood, mucus, and uterine tissue after delivery. This bleeding can continue for up to six weeks, and coloration can change from bright red blood (lochia rubra) to pinkish-brown discharge (lochia serosa).

Example Question #92 : Ethics, Processing, And Care

A new mother comes in two weeks postpartum. She is complaining of left breast tenderness and heat. On PE you note a slightly enlarged left breast that is mildly erythematous and very tender on palpation. This is most likely what condition?  

Possible Answers:

Fibrocystic breast disorder

Ductal carcinoma

Benign cyst

Mastitis

Correct answer:

Mastitis

Explanation:

Mastitis is an inflammation of the breast tissue, often due to milk stasis in a breastfeeding individual and occurring most commonly in the first few weeks after delivery. Causes can include poor latching, tight bras or clothing, or infection. Incidence is higher in individuals who are immunocompromised, and in people with cracked nipples or a past history of mastitis with a previous birth. Mastitis is not an emergency, nor is it any type of cancer, cyst, or serious breast disease.

Example Question #43 : Care

How long with the umbilical cord stump generally remain on a newborn?

Possible Answers:

2-5 days

1 week

4 weeks

2-3 weeks

Correct answer:

2-3 weeks

Explanation:

The stump of the umbilical cord will generally remain for 2-3 weeks after delivery. During that time the stump's coloration will change from blue to black as it dries. Eventually it will fall off much like a healing scab, leaving behind the umbilicus (navel).  

Example Question #44 : Care

Which of the following might be signs of an umbilical cord stump infection?  

Possible Answers:

Bleeding as the stump falls off

Blackening of the umbilical cord stump

Pus and swelling around the umbilicus

Frequent crying

Correct answer:

Pus and swelling around the umbilicus

Explanation:

An umbilical cord stump will normally turn black and may bleed slightly when it falls off. These are not signs of infection. If, however, there is pus or swelling around the umbilicus, this may be signs of infection and should be further evaluated by a pediatrician. Newborns cry for many different reasons - this is not necessarily a sign of physical illness or infection. 

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