NCLEX : Ethics, Processing, and Care

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #1 : Patient Specific Care

By what age should an infant have doubled it's birth weight?

Possible Answers:

3 months

12 months

9 months

6 months

Correct answer:

6 months

Explanation:

An infant should have doubled it's birth weight by the age of six months, and tripled it's birth weight by the age of 12 months. Children who fail to reach these markers may be underweight due to a variety of factors such as underfeeding, metabolic disorder, or failure to thrive.

Example Question #82 : Procedures And Care

Which of the following is not part of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for autism spectrum disorder (ASD)?

Possible Answers:

Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

Highly restricted, fixated interests that are abnormal in intensity or focus

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment

Stereotyped or repetitive motor movements, use of objects, or speech

Correct answer:

Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

Explanation:

All of the behaviors listed are part of the diagnostic criteria for autism spectrum disorder except for disruptive hyperactivity-impulsivity present for a period of greater than six months, which is part of the DSM-5's diagnostic criteria for attention deficit hyperactivity disorder (ADHD), not for autism spectrum disorder (ASD). 

Example Question #83 : Procedures And Care

A mother brings her seven year old daughter into the emergency room after she fell while riding her bike. She was not wearing a helmet and she hit her head on the asphalt.

Which of the following is not a sign of late-stage increased intracranial pressure (ICP) in a pediatric patient?

Possible Answers:

Fixed, dilated pupils

Bradycardia

Diminished level of consciousness

Dilated scalp veins

Correct answer:

Dilated scalp veins

Explanation:

Diminished level of consciousness, bradycardia, and fixed and dilated pupils are all signs of later-stage intracranial pressure (ICP). Dilated scalp veins may be present with ICP, but will be seen in the early stages of the condition. 

Example Question #84 : Procedures And Care

A nurse is instructing a parent on proper care for their seven-year-old son who has recently been diagnosed with a seizure disorder. In regards to care during a seizure, the nurse should advise the parent to do all of the following except __________.

Possible Answers:

Note the length of the seizure

Place a padded tongue blade in the child's mouth

Move furniture away

Stay with the child for the duration of the episode

Correct answer:

Place a padded tongue blade in the child's mouth

Explanation:

A parent of a child with a seizure disorder should be instructed to stay with the child through the duration of the seizure, to move any nearby furniture out of the way of the child to prevent trauma, and to note and record the length of the seizure. No object should ever be put into the mouth of a child who is having a seizure.

Example Question #85 : Procedures And Care

Which of the following would increase suspicion of strabismus in a pediatric patient?

Possible Answers:

The child complains of frequent nausea

The child consistently squints or tilts head to see

The child does not respond to loud or sudden noises

Difficulty holding eye contact or responding to social cues

Correct answer:

The child consistently squints or tilts head to see

Explanation:

Strabismus is a misalignment of the eyes that results in one eye becoming dominant over the other. It does not affect hearing or ability to connect to others socially. This condition should not result in nausea.

Example Question #1 : Patient Specific Care

The nurse in the primary care clinic meets with a 22-month-old boy and his mother, who is concerned about his sleeping habits. He cannot sleep without a bottle of milk and wakes during the night to ask for more. What should the nurse tell the child’s mother?

Possible Answers:

“Let him have one bottle of milk at bedtime, but do not give a second bottle.”

“Put juice in the bottle instead of milk.”

“He can have a bottle of milk before bedtime, and you can give him another bottle when he asks.”

“It is better for you to leave him with water instead of milk.”

“Do not let him have any bottles in the crib.”

Correct answer:

“It is better for you to leave him with water instead of milk.”

Explanation:

Babies and toddlers should not fall asleep with bottles full of milk or juice with them at bedtime. Plain water would be acceptable for a child to have at bedtime, as it does not have any sugar. The sugar in milk and juice will remain in the child’s mouth during sleep and cause caries, even if the teeth are not fully formed. It is common for babies to lose interest in bottles at night time when water is substituted.

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.

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