NCLEX RN PEARSON TESTBANK-QUESTIONS, ANSWERS&RATIONALES 2023
The labor and delivery nurse would make it a priority to assess which of the following two
... [Show More] newborn body systems immediately after birth?
Gastrointestinal and hepatic
Urinary and hematologic
Neurologic and temperature control
Respiratory and cardiovascular
The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to meet standards would cause a 10-year-old child to develop a sense of which of the following?
Shame
Guilt
Inferiority
Role confusion
The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report?
Steatorrhea
Increased appetite
Cheerful behavior
Soft, formed stools
During which of the following procedures should the labor and delivery nurse wear protective goggles in addition to gloves?
Changing a soaked disposable bed pad
Assisting during an amniotomy
Starting an intravenous line
Washing dirty instruments
client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders?
Increased gastric motility
Peaked T waves on 12-lead ECG
Muscle spasms
Muscle weakness
When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that the client understands that:
Defense mechanisms should not be used.
Some anxiety can be helpful.
He should strive to never experience anxiety.
He should try to avoid the fight or flight response.
nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which of the following statements indicates client understanding?
“I’ll take a walk after dinner each evening.”
“I’ll have a cigarette after meals to relax.”
“I’ll chew gum between meals to curb my appetite.”
“I’ll eat a lot of fresh vegetables and fruits.”
female client state that she will not undergo any invasive testing for her “stomach pain.” The nurse explains that which of the following tests could be completed to assess the abdomen and still meet the client’s wishes?
Abdominal ultrasound
Barium swallow
Colonoscopy
CT scan with contrast
Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits pressured, rapid speech; elevated pulse and blood pressure; palpitations; and preoccupation with her pain, despite negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis?
Pain
Anxiety
Hopelessness
Disturbed body image
The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice?
Palms of the hands or soles of the feet
Hard palate of oral cavity
Sclera
Conjunctivae
primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse’s best response is:
“Your fetus will move any day now. Call me in a week if you don’t feel it.”
“Your fetus will begin moving at about 20 week’s gestation.”
“You should have been feeling the movement already.”
“Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month.”
The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is diapered as shown. The nurse would respond that this method of diapering will help to:
Protect the urinary stent that has been put in place.
Adequately measure the urinary output.
Provide for maximum absorption of urine.
Provide optimal protection of perineal skin from infected urine.
56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse anticipates that this client is likely to be experiencing which normal developmental pattern?
6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non-REM (NREM) sleep.
6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep.
Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep.
Light sleep with equal amounts of REM sleep and NREM sleep.
While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions?
Notify the physician immediately.
Have the client cough.
Continue to monitor the system.
Reposition the chest tube.
Which nutritional measure would help a client with gastroesophageal reflux disease (GERD) to minimize the risk of symptoms?
Eating 3 large meals a day with no snacks
Using a lot of garlic to season food rather than salt
Limiting intake of coffee drinks to 2 or fewer cups a day
Using peppermint candies to take away the bitter taste in the mouth
A client who is 20 weeks gestation is concerned about how to tell her 3-year-old son about her pregnancy. Which of the following would be the best statement when counseling this client?
“If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him.”
“Tell him that he is going to have a lot of responsibilities in helping care for the baby.”
“Try to provide extra attention to him and include him in plans for the baby.”
“Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with the baby.” [Show Less]