Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 140

1. The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

A) Give her a small soft blanket to hold
B) Give her good perineal care after each diaper change
C) Leave the door open to her room
D) Pick her up when she cries

2. A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:

A) Advise the mother not to give her aspirin
B) Ask if the client is allergic to aspirin before giving further information
C) Assess the function of the client - s cranial nerve VIII
D) Check the aspirin bottle label to determine milligrams per tablet

3. A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

A) Assembling a puzzle with large pieces
B) Being taken for a wheelchair ride
C) Listening to a story about the Muppets
D) Watching Sesame Street on television

4. A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

A) Blood pressure increase from 100/80 to 115/85 after lunch
B) Headache that is unresponsive to acetaminophen (Tylenol)
C) Pulse rate ranges between 68 bpm and 76 bpm
D) Temperature rise to 102_F rectally

5. A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:

A) Limit activities which require focusing (close vision)
B) Take more frequent naps
C) Use artificial tears
D) Wear a patch over one eye

1. Right Answer: D
Explanation: (A) A soft blanket may be comforting, but it is not directed toward developing a sense of trust. (B) Good perineal care is important, but it is not directed toward developing a sense of trust. (C) An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. (D) Consistently picking her up when she cries will help the child feel trust in her caregivers.

2. Right Answer: A
Explanation: (A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reyes syndrome in children and adolescents. Children and adolescents should not be given aspirin. (B) Allergy to aspirin is not related to Reyes syndrome. (C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reyes syndrome. (D) A 6-year-old child should not be given any baby aspirin.

3. Right Answer: A
Explanation: (A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to 'do it herself.' (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.

4. Right Answer: D
Explanation: (A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

5. Right Answer: D
Explanation: (A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.

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