NCLEX : Patient-Specific Care
Study concepts, example questions & explanations for NCLEX
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Example Questions
Example Question #16 : Infant And Postpartum Care
A new mother is holding her infant just moments after delivery. After she is able to rest for a short time, she looks down and notices that her newborn is covered in fine, but fairly dark hair. This is on the infant's arms, legs, and back. She is startled and asks the nurse if this is a sign of any disorder. How should the nurse reply?
This is a sign of a serious metabolic disorder
This is abnormal - a hormone profile is required to rule out hormonal disorder
This is normal - it should be shed in a few days
This may be normal - the child should be monitored
This is normal - it should be shed in a few days
Fine, downy hair, called lanugo, generally appears on the fetus around five months of gestation. It is often shed before birth, but some infants are born with this hair still intact. The hair is normally shed within the first 1-3 weeks of life. In most cases it is entirely normal and not a sign of hormone or metabolic disorder.
Example Question #21 : Infant And Postpartum Care
A young couple presents to a clinic with a seven year old who has varicella (chicken pox). The child is not in any distress and the virus seems to be progressing normally. They are concerned, however, because one of them is currently pregnant with their second child. They are at 31 weeks of gestation. The carrying mother had chicken pox when she was 2 years old. They ask the nurse if they should be concerned for the health of the unborn child. Which of the following is the most appropriate response?
There is mild need for concern - fetal monitoring is recommended
There is no need for concern
The mother should not be in contact with the 7 year old till the last lesion is scabbed over
Frequent hand washing is recommended to prevent passing of the viral load to the fetus
There is no need for concern
As long as the carrying mother has had varicella, she will be able to pass the antibodies to the virus through the placenta to the unborn child. This will confer passive immunity to the fetus. This immunity lasts for the first few months after birth, so newborns delivered by mothers with immunity to varicella will remain immune for some time even after delivery. Increased immunity to this and other pathogens is conferred by breast milk, which contains maternal antibodies (mostly IgA).
Example Question #53 : Care
By five months of age, what change would be expected in an infant's weight?
Triple
Double
Increase by at least 50%
Increase by at least 70%
Double
An infant would be expected to double it's birth weight by five months. Some infants may double their birth weight by three to four months. An infant that has surpassed five months without approaching twice their birth weight may need to be evaluated for feeding difficulties or failure to thrive.
Example Question #103 : Procedures And Care
At what time does molding (the elongation of the baby's head as it passes through the birth canal) resolve in a newborn?
10-14 days
1-5 days
Less than 24 hours
2-3 weeks
1-5 days
Molding, or the elongation of the infants head during labor and delivery, is a normal adaptation allowing the relatively large skull to traverse the narrow space of the birth canal. It generally resolves in 1-5 days.
Example Question #31 : Patient Specific Care
How long after birth should a newborn pass meconium?
2-6 hours
3-5 days
24 hours
2 weeks
24 hours
Meconium is a sticky, dark-green to black stool that is the first stool passed by neonates after birth. It is composed of the content of the infant's digestive tract before it has begun drinking milk - primarily water, mucus, bile, lanugo, and intestinal epithelial cells. A newborn that has begun to feed on breastmilk or formula should pass a normal stool (yellow to mustard-green and creamy rather than sticky) within 24 hours.
Example Question #32 : Patient Specific Care
The nurse counsels the mother of a 2-month-old infant. Which of the following actions by the mother would be inappropriate?
The mother waits 6 months before introducing infant cereals to the baby’s diet.
The mother places the infant on her back during naps and at bedtime.
The mother makes eye contact when she speaks to the baby.
The mother swaddles the child in blankets for naps.
The mother lets her cry for 5 minutes before responding if the baby cries at night.
The mother lets her cry for 5 minutes before responding if the baby cries at night.
Infants younger than 6 months may have trouble sleeping for long periods of time because they awaken from hunger. Their stomachs are not yet large enough to hold enough nourishment to keep them asleep during the night. After 6 months, it is more appropriate to let babies cry themselves and put themselves to sleep, but before 6 months, it is not recommended. The other actions are appropriate: infants should sleep on their backs to prevent sudden infant death syndrome (SIDS), babies should be interacted with frequently, breastmilk is recommended exclusively for the first 6 months, and swaddling the child is important because the infant cannot sleep in loose blankets.
Example Question #112 : Procedures And Care
The nurse is discussing end-of-life care procedures with an elderly patient who is Buddhist. The nurse knows that the patient will most likely want to incorporate:
No autopsy and cremation
Time for meditation
Prayers to provide support and comfort
No blood transfusions
Time for meditation
Buddhists will want time for meditation, and may refuse medications that alter awareness. A shrine to Buddha may be placed in the client's room.
Example Question #2 : Gerontology And End Of Life Care
The nurse cares for an 82-year-old woman with frequent constipation. Which of the following statements by the nurse would be inappropriate?
“You can take a laxative whenever you want to have a bowel movement.”
“Make sure you are well hydrated. 6-8 glasses of water a day would be good.”
“It could help to remove dairy products like milk and cheese from your diet.”
“You should eat dark green vegetables and whole grains.”
“You can try light exercise for at least 30 minutes every day.”
“You can take a laxative whenever you want to have a bowel movement.”
Elderly patients may suffer from bowel problems like constipation due to lower motility in the gastrointestinal tract. The nurse should advise this client to exercise daily (to increase blood flow to the GI tract), stay hydrated (to prevent hard, dry stools), eat more fiber (such as fruits, vegetables, nuts, grains, and beans), and stay away from milk and cheese (as lactose sensitivity is common and may be a cause of constipation or bloating). This patient should not take laxatives each time a bowel movement is expected; reliance on laxatives is not recommended because it can desensitize the bowel and make constipation worse.
Example Question #33 : Patient Specific Care
An emergency room nurse is assessing a 26 year old female patient who frequently uses opium. What symptoms would indicate that she is experiencing withdrawal?
Diaphoresis, seizures, and apathy
Irritability, tremors, and seizures
Fatigue, disorientation, and craving
Nausea, vomiting, and anxiety
Nausea, vomiting, and anxiety
Anxiety, nausea, and vomiting are common symptoms of opium withdrawal.
Example Question #34 : Patient Specific Care
A nurse is monitoring an 18 year old who is experiencing heroin withdrawal. What symptoms might the nurse observe?
Coma and convulsions
Seizures, tremors, and tachycardia
Nausea and fainting
Yawning, cramps, and diarrhea
Yawning, cramps, and diarrhea
Yawning, cramps, and diarrhea are common signs of heroin withdrawal.
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