Published - Thu, 23 Feb 2023

NCLEX-PN Exam Questions - Part 3

1. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

A) administering immune globulin intravenously
B) assessing the extremities for edema, redness and desquamation every 8 hours
C) explaining progression of the disease to the client and his or her family
D) assessing heart sounds and rhythm

2. Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

A) immobility
B) altered growth and development
C) hemarthrosis
D) altered family processes

3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

A) 'I will assist you in arranging to have a medicine woman present.'
B) 'We do not allow medicine women in exam rooms.'
C) 'That does not make any difference in the outcome.'
D) 'It is old-fashioned to believe in that.'

4. All of the following should be performed when fetal heart monitoring indicates fetal distress except:

A) increase maternal fluids.
B) administer oxygen.
C) decrease maternal fluids.
D) turn the mother.

5. Which fetal heart monitor pattern can indicate cord compression?

A) variable decelerations
B) early decelerations
C) bradycardia
D) tachycardia

1. Right Answer: C
Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease. Health Promotion and Maintenance

2. Right Answer: D
Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infants development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client.Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac. Health Promotion and Maintenance

3. Right Answer: A
Explanation: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional. Reduction of Risk Potential

4. Right Answer: C
Explanation: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated. Reduction of Risk Potential

5. Right Answer: A
Explanation: Variable decelerations can be related to cord compression. The other patterns are not. Reduction of Risk Potential

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