NCLEX-RN : Patient-Specific Care
Study concepts, example questions & explanations for NCLEX-RN
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Example Questions
Example Question #1 : Patient Specific Care
By what age should an infant be able to pull itself up to standing?
6 months
12 months
9 months
18 months
9 months
An infant should have the ability to pull itself up to standing by the age of 9 months. If standing is not seen after 12 months the child should be evaluated for any type of physical developmental disabilities or delays.
Example Question #2 : Patient Specific Care
At what age can an infant begin eating solid foods?
3 months
6 months
4 months
9 months
6 months
Solid foods should not be introduced into an infant's diet before 6 months of age. Earlier introduction may trigger specific food allergies, as well as reducing breastmilk production in a breastfeeding mother.
Example Question #3 : Pediatric Care And Development
An audible click when the examiner slips the femoral head forward is considered positive for what sign?
Babinski sign
Ortolani sign
Scarf sign
Brudzinski sign
Ortolani sign
An audible click when the examiner slips the femoral head forward is considered a positive Ortolani sign. This finding suggests congenital hip dysplasia. Babinski sign is the presence of the Babinski reflex, which is normal in infants. Scarf sign is used to assess developmental age and muscle tone in neonates. Brudzinski sign is not related to the musculoskeletal system but is part of a physical examination in cases of suspected meningitis.
Example Question #3 : Patient Specific Care
At what age does the posterior fontanelle close?
16 weeks
8 weeks
4 weeks
12 weeks
8 weeks
The posterior fontanelle, which is the cartilaginous gap at the junction of the lambdoid suture and the sagittal suture, closes at eight weeks of age.
Example Question #4 : Patient Specific Care
By what age should an infant have doubled it's birth weight?
3 months
6 months
9 months
12 months
6 months
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)?
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
Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level
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?
Fixed, dilated pupils
Bradycardia
Diminished level of consciousness
Dilated scalp veins
Dilated scalp veins
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 __________.
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
Place a padded tongue blade in the child's mouth
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?
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
The child consistently squints or tilts head to see
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?
“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.”
“It is better for you to leave him with water instead of milk.”
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.
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