NCLEX-RN : Care
Study concepts, example questions & explanations for NCLEX-RN
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Example Questions
Example Question #61 : 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 lets her cry for 5 minutes before responding if the baby cries at night.
The mother swaddles the child in blankets for naps.
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 waits 6 months before introducing infant cereals to the baby’s diet.
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 #62 : Care
The nurse performs triage in the emergency department for a patient with a bee sting. The family reports a history of allergic reactions to bee stings, and the patient complains of difficulty breathing and swelling in his mouth. Which of the following is the priority of the nurse?
Administer subcutaneous epinephrine.
Maintain an open airway.
Administer oral diphenhydramine.
Obtain a full patient history.
Contact the physician.
Maintain an open airway.
Follow the ABC's of nursing priority: airway, breathing, circulation. It is most most important for the nurse to maintain a patent airway, as the symptoms manifested suggest an anaphylactic reaction. Epinephrine may be given after the airway is established. Oral diphenhydramine is usually given for mild allergic reactions. The physician may be contacted later; patient safety is the priority.
Example Question #63 : 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
No blood transfusions
Time for meditation
Prayers to provide support and comfort
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 #64 : Care
The nurse cares for an 82-year-old woman with frequent constipation. Which of the following statements by the nurse would be inappropriate?
“It could help to remove dairy products like milk and cheese from your diet.”
“Make sure you are well hydrated. 6-8 glasses of water a day would be good.”
“You should eat dark green vegetables and whole grains.”
“You can take a laxative whenever you want to have a bowel movement.”
“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 #1 : Alcohol And Drug Abuse
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?
Nausea, vomiting, and anxiety
Fatigue, disorientation, and craving
Irritability, tremors, and seizures
Diaphoresis, seizures, and apathy
Nausea, vomiting, and anxiety
Anxiety, nausea, and vomiting are common symptoms of opium withdrawal.
Example Question #1 : Alcohol And Drug Abuse
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
Yawning, cramps, and diarrhea
Nausea and fainting
Yawning, cramps, and diarrhea
Yawning, cramps, and diarrhea are common signs of heroin withdrawal.
Example Question #2 : Alcohol And Drug Abuse
Which of the following drugs is considered a central nervous system (CNS) depressant?
Atenolol
Marijuana
All of these
Cyclobenzaprine
All of these
All of the drugs listed are considered to be CNS depressants. While generally classified as a psychedelic, marijuana has multiple central depressant effects such as sedation and muscle relaxation. Also, alcohol is another commonly used depressant.
Example Question #3 : Alcohol And Drug Abuse
Alcohol abuse-induced thiamine deficiency can cause which of the following?
Agnosia
Lewy body dementia
Wernicke-Korsakoff syndrome
Wolf-Hirschhorn syndrome
Wernicke-Korsakoff syndrome
Wernicke-Korsakoff syndrome is caused by a severe deficiency in thiamine, often seen in severe alcohol dependency. It is characterized by visual disturbances, ataxia, and altered consciousness. Wolf-Hirschhorn syndrome is a genetic disorder causing developmental disability and may involve seizures. Lewy body dementia is associated with Parkinson's disease. Agnosia is a neurological disorder causing impaired ability to process sensory information.
Example Question #1 : Alcohol And Drug Abuse
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) criteria for substance abuse includes all of the following except __________.
continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance
recurrent substance use in situations in which it is physically hazardous
recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
All of these are part of the DSM V criteria for substance abuse
All of these are part of the DSM V criteria for substance abuse
All of the items listed are part of the DSM V criteria for substance abuse. In addition, the individual's symptoms must not qualify for substance dependence and recurrent substance-related legal problems are other DSM V criteria for substance abuse.
Example Question #2 : Alcohol And Drug Abuse
A 42 year old man presents to the ER for alcohol toxicity. While taking the history, the nurse discovers that he drinks on average one fifth of vodka per night, and often must drink an additional 6-12oz to get "a good buzz." When he doesn't drink, he experiences tremors and feels unwell until he is able to drink again. When asked if he would like to quit drinking he states that he has tried unsuccessfully several times over his life. He knows that he needs to get control over his drinking because it is seriously impairing his relationship with his husband and their 13 year old daughter.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V), this patient can be considered to have which of the following conditions?
Substance abuse
None of these
Substance addiction
Substance dependency
Substance dependency
The symptoms described by this patient put his alcohol use in the category of substance dependency, according to the DSM V, a more severe form of abuse than substance addiction. The criteria for this condition are:
- Tolerance
- Withdrawal
- Unintentional excesses in consumption
- Persistent desire or unsuccessful efforts to reduce or control substance use
- A great deal of time is spent to get, use, or recover from the substance
- Interference with social life
- The substance use is continued despite knowledge problems caused by use
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