NCLEX-RN Practice Quiz Test Bank #2 (75 Questions), Exams of Biology

Download NCLEX-RN Practice Quiz Test Bank #2 (75 Questions) and more Exams Biology in PDF only on Docsity! NCLEX-RN Practice Quiz Test Bank #2 (75 Questions) NCLEXRN-02-001 Question Tag: confusion Question Category: Physiological Integrity, Reduction of Risk Potential A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?  A. Blood sugar check  B. CT scan  C. Blood cultures  D. Arterial blood gases Correct Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels.  Option B: Performing CT scan at this stage of assessment is unnecessary. A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide more- detailed information than plain X-rays do.  Option C: A blood culture test helps the doctor figure out if the client has a kind of infection that is in the bloodstream and can affect the entire body. Doctors call this a systemic infection. The test checks a sample of the blood for bacteria or yeast that might be causing the infection.  Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in the blood. It also measures the body’s acid-base (pH) level, which is usually in balance when healthy. NCLEXRN-02-002 Question Tag: toilet training Question Category: Health Promotion and Maintenance A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training?  A. The age of the child  B. The child’s ability to understand instruction.  C. The overall mental and physical abilities of the child.  D. Frequent attempts with positive reinforcement. Correct Answer: C. The overall mental and physical abilities of the child. Age is not the greatest factor in potty training. The overall mental and physical abilities of the child are the most important factor.  Option A: Readiness for toilet training varies with every age of the child.  Option B: A child who can follow simple instructions may start toilet training. However, it is not considered as the most important factor.  Option D: Positive reinforcement is a great tool for toilet training, yet, it may not be the most important one. NCLEXRN-02-003 Question Tag: poisoning Question Category: Safety and infection Control A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?  Option C: Asking a coworker would be inappropriate and against patient’s confidentiality. NCLEXRN-02-006 Question Tag: hyperparathyroidism Question Category: Physiological Integrity, Reduction of Risk Potential A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings?  A. Elevated serum calcium  B. Low serum parathyroid hormone (PTH)  C. Elevated serum vitamin D  D. Low urine calcium Correct Answer: A. Elevated serum calcium. The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in osteopenia.  Option B: Parathyroid hormone levels may be high or normal but not low. The main effects of parathyroid hormone are to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney, and increasing renal production of 1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of calcium.  Option C: The body will lower the level of vitamin D in an attempt to lower calcium. Vitamin D levels should be measured in the evaluation of primary hyperparathyroidism. Vitamin D deficiency (a 25-hydroxyvitamin D level of less than 20 ng per milliliter) can cause secondary hyperparathyroidism, and repletion of vitamin D deficiency can help to reduce parathyroid hormone levels.  Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. In addition, the chronically increased excretion of calcium in the urine can predispose to the formation of renal stones. NCLEXRN-02-007 Question Tag: Addison’s disease Question Category: Health Promotion and Maintenance A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?  A. A diet high in grains  B. A diet with adequate caloric intake  C. A high protein diet  D. A restricted sodium diet Correct Answer: D. A restricted sodium diet. A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Patients should eat an unrestricted diet. Those with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Infants with primary adrenal insufficiency often need 2-4 g of sodium chloride per day.  Option A: A well-balanced diet is the best way to keep the body healthy and to regulate sugar levels. Doctors recommend balancing protein, healthy fats, and high-quality, nutrient-dense carbohydrates.  Option B: High-calorie comfort food reduces symptoms of neuroglycopenia in Addison patients, suggesting that Addison’s disease is associated with a deficit in cerebral energy supply that can partly be alleviated by intake of palatable food.  Option C: Healthy fats and high-quality proteins slow the blood sugar rollercoaster and promote stable blood sugar levels throughout the day. NCLEXRN-02-008 Question Tag: diabetes mellitus, cholecystectomy Question Category: Physiological Integrity, Physiological Adaptation A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms?  A. Anesthesia reaction  B. Hyperglycemia  C. Hypoglycemia  D. Diabetic ketoacidosis Correct Answer: C. Hypoglycemia A postoperative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. Reduction in cerebral glucose availability (ie, neuroglycopenia) can manifest as confusion, difficulty with concentration, irritability, hallucinations, focal impairments (eg, hemiplegia), and, eventually, coma and death.  Option A: An anesthesia reaction would not occur on the second postoperative day. The adrenergic symptoms often precede the neuroglycopenic symptoms and, thus, provide an early warning system for the patient. Studies have shown that the primary stimulus for the release of catecholamines is the absolute level of plasma glucose; the rate of decrease of glucose is less important.  Option B: Neuropathy affects up to 50% of patients with type 1 DM, but symptomatic neuropathy is typically a late development, developing after many years of chronic prolonged hyperglycemia. Peripheral neuropathy presents as numbness and tingling in both hands and feet, in a glove-and- stocking pattern; it is bilateral, symmetric, and ascending.  Option D: Symptoms of hyperglycemia associated with diabetic ketoacidosis may include thirst, polyuria, polydipsia, and nocturia. NCLEXRN-02-011 Question Tag: hepatitis A Question Category: Safe and Effective Care Environment, Safety and Infection Control A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission?  A. Sexual contact with an infected partner  B. Contaminated food  C. Blood transfusion  D. Illegal drug use Correct Answer: B. Contaminated food. Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results almost exclusively from ingestion (eg, fecal-oral transmission)  Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is commonly transmitted via body fluids such as blood, semen, and vaginal secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing of needles, blood transfusions, and organ transplantation are routes for HBV infection.  Option C: Before widespread screening of the blood supply in 1992, hepatitis C was also spread through blood transfusions and organ transplants. Now, the risk of transmission to recipients of blood or blood products is extremely low.  Option D: Today, most people become infected with hepatitis B, C, or D by sharing needles, syringes, or any other equipment used to prepare and inject drugs. NCLEXRN-02-012 Question Tag: leukemia, blood transfusion Question Category: Safe and Effective Care Environment, Safety and Infection Control A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?  A. A history of hepatitis C five years previously  B. Cholecystitis requiring cholecystectomy one year previously  C. Asymptomatic diverticulosis  D. Crohn’s disease in remission Correct Answer: A. A history of hepatitis C five years previously Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient.  Option B: Cholecystitis is the inflammation of the gallbladder. This condition does not transmit through bodily fluids.  Option C: Diverticulosis is when pockets called diverticula form in the wall of the digestive tract. The inner layer of the intestine pushes through weak spots in the outer lining. This pressure makes them bulge out, making little pouches.  Option D: Crohn’s disease is an inflammatory bowel disease. It causes inflammation of the digestive tract. This disease does not transmit through the blood. NCLEXRN-02-013 Question Tag: acute gastritis Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient?  A. Naproxen sodium (Naprosyn)  B. Calcium carbonate  C. Clarithromycin (Biaxin)  D. Furosemide (Lasix) Correct Answer: A. Naproxen sodium (Naprosyn). Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Naproxen is used to relieve pain from various conditions such as headache, muscle aches, tendonitis, dental pain, and menstrual cramps. It also reduces pain, swelling, and joint stiffness caused by arthritis, bursitis, and gout attacks.  Option B: Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription.  Option C: Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Clarithromycin is used to treat certain bacterial infections, such as pneumonia (a lung infection), bronchitis (infection of the tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat. It also is used to treat and prevent disseminated Mycobacterium avium complex (MAC) infection [a type of lung infection that often affects people with human immunodeficiency virus (HIV)]. It is used in combination with other medications to eliminate H. pylori, a bacterium that causes ulcers. Clarithromycin is in a class of medications called macrolide antibiotics. It works by stopping the growth of bacteria.  Option D: Furosemide is a loop diuretic and is not contraindicated in a patient with gastritis. Furosemide is used alone or in combination with other medications to treat high blood pressure. Furosemide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various NCLEXRN-02-016 Question Tag: cardioverter-defibrillator Question Category: Physiological Integrity, Reduction of Risk Potential A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?  A. A patient admitted for myocardial infarction without cardiac muscle damage.  B. A postoperative coronary bypass patient, recovering on schedule.  C. A patient with a history of ventricular tachycardia and syncopal episodes.  D. A patient with a history of atrial tachycardia and fatigue. Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary for a patient with significant ventricular symptoms, such as tachycardia resulting in syncope.  Option A: A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate.  Option B: A patient recovering well from coronary bypass would not need the device.  Option D: Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort. NCLEXRN-02-017 Question Tag: MRI, lung cancer Question Category: Physiological Integrity, Reduction of Risk Potential A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?  A. The patient is allergic to shellfish.  B. The patient has a pacemaker.  C. The patient suffers from claustrophobia.  D. The patient takes antipsychotic medication. Correct Answer: B. The patient has a pacemaker. The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Patients with cardiac implantable electronic devices or CIED are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. These patients must be scheduled in a CIED blocked slot or scheduled with electrophysiology nurse or technician support. But nowadays MRI conditional cardiac implantable electronic devices are widely available.  Option A: Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. MRI contrast agents are gadolinium chelates with different stability, viscosity, and osmolality. Gadolinium is a relatively very safe contrast; however, it rarely might cause allergic reactions in patients.  Options C: Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Claustrophobic patients might refuse to complete the MRI scan and need sedation. These patients need to be well informed about the MRI scan procedure. The recommendation is that a physician has a discussion with them about the details in advance. Using Larger and opener MRI systems might be helpful in claustrophobic patients.  Option D: Psychiatric medication is not a contraindication to MRI scanning. MRI helps in high-resolution investigations of soft tissues without the use of ionizing radiation. This safe modality currently becomes the imaging technique of choice for diagnosing musculoskeletal, neurologic, and cardiovascular disease. However, there are restrictions and contraindications caused by MRI magnetic fields, machine structure, and gadolinium contrast agents. NCLEXRN-02-018 Question Tag: pulmonary embolism Question Category: Physiological Integrity, Physiological Adaptation A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?  A. The patient is somnolent with decreased response to the family.  B. The patient suddenly complains of chest pain and shortness of breath.  C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs.  D. The patient has a fever, chills, and loss of appetite. Correct Answer: B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism—must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed.  Option A: The patient may present atypical symptoms based on risk factors, such as delirium or decreasing level of consciousness.  Option B: The diagnosis of pulmonary embolism should be sought actively in patients with respiratory symptoms unexplained by an alternative diagnosis; symptoms may include productive cough and wheezing.  Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients; however, temperature higher than 39.5°C (103.1º) F is not from pulmonary embolism. NCLEXRN-02-021 Question Tag: increased intracranial pressure Question Category: Physiological Integrity, Physiological Adaptation A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?  A. Bulging anterior fontanel  B. Repeated vomiting  C. Signs of sleepiness at 10 PM  D. Inability to read short words from a distance of 18 inches Correct Answer: B. Repeated vomiting. Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life-threatening. Repeated vomiting can be an early sign of pressure as the vomiting center within the medulla is stimulated.  Option A: The anterior fontanel is closed in a 4-year-old child. The average closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will closer sooner compared to female infants.  Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. Young toddlers have a sleep schedule supplemented by two naps a day. Toddler sleep problems are compounded by separation anxiety and a fear of missing out, which translates to stalling techniques and stubbornness at bedtime.  Option D: The average 4-year-old child cannot read yet, so this too is normal. At 4, many children just aren’t ready to sit still and focus on a book for long. Others may learn the mechanics of reading but aren’t cognitively ready to comprehend the words. NCLEXRN-02-022 Question Tag: rubeola Question Category: Health Promotion and Maintenance A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?  A. Small blue-white spots are visible on the oral mucosa.  B. The rash begins on the trunk and spreads outward.  C. There is low-grade fever.  D. The lesions have a “teardrop-on-a-rose-petal” appearance. Correct Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa opposite the second molars. The Koplik spots generally are first seen 1-2 days before the appearance of the rash and last until 2 days after the rash appears. This enanthem begins to slough as the rash appears. Although this is the pathognomonic enanthem of measles, its absence does not exclude the diagnosis.  Option B: The body rash typically begins on the face and travels downward. Blanching, erythematous macules and papules begin on the face at the hairline, on the sides of the neck, and behind the ears (see the images below). Within 48 hours, they coalesce into patches and plaques that spread cephalocaudally to the trunk and extremities, including the palms and soles, while beginning to regress cephalocaudally, starting from the head and neck. Lesion density is greatest above the shoulders, where macular lesions may coalesce. The eruption may also be petechial or ecchymotic in nature.  Option C: High fever (may spike to more than 104°F) is often present. The first sign of measles is usually a high fever (often >104o F [40o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”).  Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chicken pox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal NCLEXRN-02-023 Question Tag: scarlet fever Question Category: Physiological Adaptation A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?  A. Scarlet fever is caused by infection with group A Streptococcus bacteria.  B. “Strawberry tongue” is a characteristic sign.  C. Petechiae occur on the soft palate.  D. The pharynx is red and swollen. Correct Answer: C. Petechiae occur on the soft palate. Petechiae on the soft palate are characteristic of rubella infection.  Option A: Bacteria called group A Streptococcus or group A strep cause scarlet fever. The bacteria sometimes make a poison (toxin), which causes a rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. The circulating toxin, produced by GABHS and often referred to as erythemogenic or erythrogenic toxin, causes the pathognomonic rash as a consequence of local production of inflammatory mediators and alteration of the cutaneous cytokine milieu. This results in a sparse inflammatory response and dilatation of blood vessels, leading to the characteristic scarlet color of the rash.  Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous,  Option B: Surgical intervention is unnecessary; the testes descend by one year of age. The testicles will descend normally at puberty and surgery is not needed. Testicles that do not naturally descend into the scrotum are considered abnormal. An undescended testicle is more likely to develop cancer, even if it is brought into the scrotum with surgery. Cancer is also more likely in the other testicle.  Option C: In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. NCLEXRN-02-026 Question Tag: Wilms tumor Question Category: Physiological Integrity, Physiological Adaptation A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?  A. The tumor is less than 3 cm. in size and requires no chemotherapy.  B. The tumor did not extend beyond the kidney and was completely resected.  C. The tumor extended beyond the kidney but was completely resected.  D. The tumor has spread into the abdominal cavity and cannot be resected. Correct Answer: C. The tumor extended beyond the kidney but was completely resected. The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual non hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.  Option A: The mass is solid at presentation and usually >10 cm.  Option B: This option describes stage 1, wherein the tumor is limited to the kidney and completely resected.  Option D: In stage IV, hematogenous metastasis has occurred with spread beyond the abdomen. NCLEXRN-02-027 Question Tag: acute glomerulonephritis Question Category: Physiological Integrity, Reduction of Risk Potential A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply.  A. Urine specific gravity of 1.040.  B. Urine output of 350 ml in 24 hours.  C. Brown (“tea-colored”) urine.  D. Generalized edema. Correct Answer: A, B, & C Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells.  Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts are present.  Option B: Functional changes include proteinuria, hematuria, reduction in GFR (ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal nephron salt and water retention result in expansion of intravascular volume, edema, and, frequently, systemic hypertension.  Option C: This is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients, often manifesting as smoky-, coffee-, or cola-colored urine.  Option D: There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis. Most often, the patient is a boy, aged 2-14 years, who suddenly develops puffiness of the eyelids and facial edema in the setting of a poststreptococcal infection. NCLEXRN-02-028 Question Tag: acute glomerulonephritis Question Category: Physiological Integrity, Physiological Adaptation Which of the following conditions most commonly causes acute glomerulonephritis?  A. A congenital condition leading to renal dysfunction.  B. Prior infection with group A Streptococcus within the past 10-14 days.  C. Viral infection of the glomeruli.  D. Nephrotic syndrome. Correct Answer: B. Prior infection with group A Streptococcus within the past 10-14 days. Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.  Option A: No congenital condition predisposes to glomerulonephritis. Noninfectious causes of acute GN may be divided into primary renal diseases, systemic diseases, and miscellaneous conditions or agents.  Option C: Viruses may cause acute glomerulonephritis but rarely. Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus (HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps virus are accepted as viral causes only if it can be documented that a recent group A beta-hemolytic streptococcal infection did not occur. Acute GN has been documented as a rare complication of hepatitis A.  Option D: Nephrotic syndrome does not cause acute glomerulonephritis. PSGN usually develops 1-3 weeks after acute infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. The incidence of GN is approximately 5-10% in persons with pharyngitis and 25% in those with skin infections.  Option D: Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation. The skin may have an atrophic, shiny appearance and may demonstrate trophic changes, including alopecia; dry, scaly, or erythematous skin; chronic pigmentation changes; and brittle nails. NCLEXRN-02-031 Question Tag: atherosclerosis Question Category: Health Promotion A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?  A. Family history of heart disease  B. Overweight  C. Smoking.  D. Age. Correct Answer: A. Family history of heart disease. A family history of heart disease is an inherited risk factor that is not subject to lifestyle change. Having a first-degree relative with heart disease has been shown to significantly increase risk.  Option B: Overweight is a risk factor that is subject to lifestyle change and can reduce risk significantly. The terms “overweight” and “obesity” refer to body weight that’s greater than what is considered healthy for a certain height.  Option C: Smoking can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to reach the body’s tissues.  Option D: Advancing age increases the risk of atherosclerosis but is not a hereditary factor. As one gets older, the risk for atherosclerosis increases. Genetic or lifestyle factors cause plaque to build up in the arteries as one ages. By the time one is middle-aged or older, enough plaque has built up to cause signs or symptoms. In men, the risk increases after age 45. In women, the risk increases after age 55. NCLEXRN-02-032 Question Tag: peripheral vascular disease, claudication Question Category: Physiological Integrity, Physiological Adaptation Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply:  A. It results when oxygen demand is greater than oxygen supply.  B. It is characterized by pain that often occurs during rest.  C. It is a result of tissue hypoxia.  D. It is characterized by cramping and weakness.  E. It always affects the upper extremities. Correct Answer: A, C, and D. Claudication describes the pain experienced by a patient with a peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.  Option A: Claudication refers to muscle pain due to lack of oxygen that’s triggered by activity and relieved by rest.  Option B: This most often occurs during activity when demand increases in muscle tissue.  Option C: The condition is also called intermittent claudication because the pain usually isn’t constant. It begins during exercise and ends with rest. As claudication worsens, however, the pain may occur during rest.  Option D: Claudication is pain caused by too little blood flow to muscles during exercise. Most often this pain occurs in the legs after walking at a certain pace and for a certain amount of time — depending on the severity of the condition.  Option E: Pain in the shoulders, biceps, and forearms may occur, but less often. NCLEXRN-02-033 Question Tag: peripheral vascular disease Question Category: Health Promotion and Maintenance A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?  A. Walk barefoot whenever possible.  B. Use a heating pad to keep feet warm.  C. Avoid crossing the legs.  D. Use antibacterial ointment to treat skin lesions at risk of infection. Correct Answer: C. Avoid crossing the legs. Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient.  Option A: Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection.  Option B: Heating pads can cause injury, which can also increase the risk of infection.  Option D: Skin lesions at risk for infection should be examined and treated by a physician. NCLEXRN-02-034 Question Tag: vasospastic disorder, Raynaud’s disease Question Category: Health Promotion and Maintenance Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?  A. Air embolus.  B. Cerebral hemorrhage.  C. Expansion of the clot.  D. Resolution of the clot. Correct Answer: B. Cerebral hemorrhage. Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. The success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined.  Option A: Air embolism is not a concern. Thrombosis is an important part of the normal hemostatic response that limits hemorrhage caused by microscopic or macroscopic vascular injury. Physiologic thrombosis is counterbalanced by intrinsic antithrombotic properties and fibrinolysis. Under normal conditions, a thrombus is confined to the immediate area of injury and does not obstruct flow to critical areas, unless the blood vessel lumen is already diminished, as it is in atherosclerosis.  Option C: Both hemostasis and thrombosis depend on the coagulation cascade, vascular wall integrity, and platelet response. Several cellular factors are responsible for thrombus formation. When a vascular insult occurs, an immediate local cellular response takes place. Platelets migrate to the area of injury, where they secrete several cellular factors and mediators. These mediators promote clot formation.  Option D: Thrombolytic therapy does not lead to the expansion of the clot, but to resolution, which is the intended effect. NCLEXRN-02-037 Question Tag: infant, head position Question Category: Health Promotion and Maintenance An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?  A. Torticollis, with shortening of the sternocleidomastoid muscle.  B. Craniosynostosis, with premature closure of the cranial sutures.  C. Plagiocephaly, with flattening of one side of the head.  D. Hydrocephalus, with increased head size. Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle. In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of the neck and causing the chin to point to the opposing side.  Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape.  Option C: Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time.  Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size. NCLEXRN-02-038 Question Tag: Addison’s disease Question Category: Health Promotion and Maintenance An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?  A. The condition was caused by the student’s competitive swimming schedule.  B. The student will most likely require surgical intervention.  C. The student experiences pain in the inferior aspect of the knee.  D. The student is trying to avoid participation in physical education. Correct Answer: C. The student experiences pain in the inferior aspect of the knee. Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer.  Option A: Swimming is not a likely cause. OSD is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. The pain associated will be localized to the tibial tubercle and occasionally the patellar tendon itself.  Option B: The condition is usually self-limited, responding to ice, rest, and analgesics. OSD is a self-limiting condition. In a study by Krause et al, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year after onset of symptoms. [3] After skeletal maturity, patients may continue to have problems kneeling. This typically is due to tenderness over an unfused tibial tubercle ossicle or a bursa that may require resection.  Option D: Continued participation will worsen the condition and the symptoms. The onset of OSD is usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient’s symptoms. NCLEXRN-02-039 Question Tag: assessment Question Category: Health Promotion and Maintenance Correct Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized.  Options A: Advances in treatment over the last 20 years—especially the introduction of early use of intra-articular steroids, methotrexate, and biologic medications—have dramatically improved the prognosis for children with arthritis. Almost all children with JIA lead productive lives. However, many patients, particularly those with polyarticular disease, may have problems with active disease throughout adulthood, with sustained remission attained in a minority of patients.  Option B: Children with systemic-onset disease tend to either respond completely to medical therapy or develop a severe polyarticular course that tends to be refractory to medical treatment, with disease persisting into adulthood.  Option D: Physical activity is an integral part of therapy. Encourage patients to be as active as possible. Bed rest is not a part of the treatment. In fact, the more active the patient, the better the long-term prognosis. Children may experience increased pain during routine physical activities. As a result, these children must be allowed to self-limit their activities, particularly during physical education classes. A consistent physical therapy program, with attention to stretching exercises, pain modalities, joint protection, and home exercises, can help ensure that patients are as active as possible. NCLEXRN-02-042 Question Tag: osteomyelitis Question Category: Safe and Effective Care Environment, Safety and Infection Control A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?  A. The admission orders are written.  B. A blood culture is drawn.  C. A complete blood count with differential is drawn.  D. The parents arrive. Correct Answer: B. A blood culture is drawn. Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism.  Option A: Making sure that the physician’s orders for antibiotics are written, instead of admitting orders, should be done.  Option C: The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment.  Option D: Parental presence is important for the adjustment of the child but not for the administration of medication. NCLEXRN-02-043 Question Tag: swelling, leg injury Question Category: Physiological Integrity, Physiological Adaptation A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?  A. Possible fracture of the tibia.  B. Bruising of the gastrocnemius muscle.  C. Possible fracture of the radius.  D. No anatomic injury, the child wants his mother to carry him. Correct Answer: A. Possible fracture of the tibia. The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture.  Option B: Toddlers will often continue to walk on a muscle that is bruised or strained.  Option C: The radius is found in the lower arm and is not relevant to this question.  Option D: Toddlers rarely feign injury to be carried, and swelling indicates a physical injury. NCLEXRN-02-044 Question Tag: cerebral palsy Question Category: Health Promotion and Maintenance A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply.  A. Regular developmental screening is important to avoid secondary developmental delays.  B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.  C. Developmental milestones may be slightly delayed but usually will require no additional intervention.  D. Parent support groups are helpful for sharing strategies and managing health care issues.  E. Therapies and surgical interventions can cure cerebral palsy. Correct Answer: A, B, and D. Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones. NCLEXRN-02-046 Question Tag: percutaneous transluminal coronary angioplasty Question Category: Physiological Integrity, Reduction of Risk Potential A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the  A. Surgical repair of a diseased coronary artery.  B. Placement of an automatic internal cardiac defibrillator.  C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow.  D. Non-invasive radiographic examination of the heart. Correct Answer: C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical procedure to repair a diseased coronary artery.  Option A: Coronary artery bypass grafting is the surgical repair of a diseased coronary artery.  Option B: Angioplasty does not involve the placement of an internal cardiac defibrillator. An internal cardiac defibrillator is needed if the client has ventricular tachycardia or ventricular fibrillation because they detect and stop abnormal heartbeats or arrhythmias.  Option D: PTCA is not a radiographic examination of the heart. NCLEXRN-02-047 Question Tag: hypothyroidism Question Category: Physiological Integrity, Physiological Adaptation A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize:  A. They can expect the child will be mentally retarded.  B. Administration of thyroid hormone will prevent problems.  C. This rare problem is always hereditary.  D. Physical growth/development will be delayed. Correct Answer: B. Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement correct this condition.  Option A: Mental retardation can be prevented with early detection and treatment. Neurologic sequelae, characterized by spasticity, tremor, and hyperactive deep tendon reflexes, are found frequently in severe cretinism, but not in mild cretinism or acquired hypothyroidism. The severity of neurologic sequelae parallels mental retardation. Early therapy apparently prevents, in part, these sequelae.  Option C: Congenital hypothyroidism is caused by iodine deficiency and is occasionally exacerbated by naturally occurring goitrogens. In the majority of patients, CH is caused by an abnormal development of the thyroid gland (thyroid dysgenesis) that is a sporadic disorder and accounts for 85% of cases and the remaining 15% of cases are caused by dyshormonogenesis. The clinical features of congenital hypothyroidism are so subtle that many newborn infants remain undiagnosed at birth and delayed diagnosis leads to the most severe outcome of CH, mental retardation, emphasizing the importance of neonatal screening.  Option D: The growth and development of an infant with congenital hypothyroidism can be normal if it is detected and treated early. In overt hypothyroidism, the severe impairment of linear growth leads to dwarfism, which is characterised by limbs that are disproportionately short compared with the trunk. Even in subclinical hypothyroidism, a condition of mild thyroid failure, growth velocity in children is suboptimal. NCLEXRN-02-048 Question Tag: mental illness Question Category: Psychosocial Integrity A priority goal of involuntary hospitalization of the severely mentally ill client is  A. Re-orientation to reality  B. Elimination of symptoms  C. Protection from harm to self or others  D. Return to independent functioning Correct Answer: C. Protection from self-harm and harm to others. Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.  Option A: Mentally ill clients should be kept safe first before reorienting them back to reality. In keeping with emergent mental health public policy and nursing professional ethics, the articulated aims of deinstitutionalization included returning individuals to home communities to restore freedom and autonomy, and reducing or eliminating nursing practices grounded in punishment that were being societally reconceptualized as harmful.  Option B: Gradual elimination of the symptoms is not the primary goal in the hospitalization of a mentally ill client. There are two important concepts about psychological treatment. First, although it is called “psychological” treatment, the ultimate effect of these treatments is to bring some changes in the very delicate change in the structure and function of neurons by changing the way a person habitually thinks and behaves. They also promote the healing of the brain by reducing the stress experienced by the patients in daily life. In psychological treatment, all treatment effects come from the effort to take new behaviour and adopt new ways of thinking.  Option D: The client should be kept safe from himself and others first before he can return to independent functioning. The measurement of functional capacity in mental illness is an important recent development. Determination of functional capacity may serve as a surrogate marker for  Option C: Hemorrhage is not a great risk in premature rupture of membranes. One of the complications of PROM is intraventricular hemorrhage. This is because blood vessels in the brain of premature infants are not fully developed, and are therefore weaker than that of term babies. Research shows that intraventricular hemorrhages (IVH) or brain bleeds are significantly reduced by steroid treatment, without an increase in either maternal or neonatal infection. NCLEXRN-02-051 Question Tag: hip spica cast Question Category: Physiological Integrity, Physiological Adaptation A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:  A. Expose the cast to air and turn the child frequently.  B. Use a heat lamp to reduce the drying time.  C. Handle the cast with the abductor bar.  D. Turn the child as little as possible. Correct Answer: A. Expose the cast to air and turn the child frequently The child should be turned every 2 hours, with the surface exposed to the air. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm.  Option B: Heat lamps may cause burns in the skin inside the cast. Inspect the skin around the cast. If the skin becomes red or raw around the cast, contact a doctor.  Option C: Do not handle the cast until it is dry because it might still break. It takes about one hour for fiberglass, and two to three days for plaster to become hard enough to walk on. Some physicians will give a “cast shoe” to wear over a walking cast. The cast shoe will help protect the bottom of the cast.  Option D: Turning the child would ensure equal drying of the cast at all sides. Keep the cast dry. If the cast becomes wet, it can hurt the child’s skin. Do not try to dry cast with something warm (i.e., a blow dryer) this may cause burns. NCLEXRN-02-052 Question Tag: intravenous pyelogram Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:  A. Instruct the client to maintain a regular diet the day prior to the examination.  B. Restrict the client’s fluid intake 4 hours prior to the examination.  C. Administer a laxative to the client the evening before the examination.  D. Inform the client that only 1 x-ray of his abdomen is necessary. Correct Answer: C. Administer a laxative to the client the evening before the examination Bowel prep is important because it will allow greater visualization of the bladder and ureters. Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the urine or pain in the side or lower back. An IVP may provide enough information to allow the doctor to treat with medication and avoid surgery.  Option A: Eating and drinking the night before the exam should be avoided.  Option B: Restriction of fluids on the night before the exam should be emphasized.  Option D: An intravenous pyelogram is an x-ray of the kidneys, ureters, and urinary bladder that uses iodinated contrast material injected into veins. NCLEXRN-02-053 Question Tag: acute glomerulonephritis Question Category: Physiological Integrity, Physiological Adaptation Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that:  A. AGN is a streptococcal infection that involves the kidney tubules.  B. The disease is easily transmissible in schools and camps.  C. The illness is usually associated with chronic respiratory infections.  D. It is not “caught” but is a response to a previous B-hemolytic strep infection. Correct Answer: D. It is not “caught” but is a response to a previous B- hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease.  Option A: Acute glomerulonephritis comprises a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium.  Option B: The disease is most commonly caused by Streptococcus species. Glomerulonephritis may develop a week or two after recovery from a strep throat infection or, rarely, a skin infection (impetigo). To fight the infection, the body produces extra antibodies that can eventually settle in the glomeruli, causing inflammation. postpartum hemorrhage. Brisk blood flow after delivery of the placenta unresponsive to transabdominal massage should prompt immediate action including bimanual compression of the uterus and use of uterotonic medications. Massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall  Option D: Perineal lacerations may be present but it is not a primary concern during uterine atony. Lacerations and hematomas due to birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Episiotomy increases the risk of blood loss and anal sphincter tears; this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor. NCLEXRN-02-056 Question Tag: developmental dysplasia Question Category: Physiological Integrity, Physiological Adaptation The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?  A. Unequal leg length  B. Limited adduction  C. Diminished femoral pulses  D. Symmetrical gluteal folds Correct Answer: A. Unequal leg length Shortening of a leg is a sign of developmental dysplasia of the hip. The hip is a “ball-and-socket” joint. In a normal hip, the ball at the upper end of the thigh bone (femur) fits firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally. The ball is loose in the socket and may be easy to dislocate.  Option B: Limited adduction is not a sign of developmental dysplasia. In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the thigh bone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that help to hold the joint in place are stretched. The degree of hip looseness, or instability, varies among children with DDH.  Option C: Femoral pulses in a client with developmental dysplasia of the hip are normal.  Option D: Asymmetric gluteal folds with uneven gluteal creases are associated with developmental hip dysplasia. NCLEXRN-02-057 Question Tag: Valsalva maneuver, acute myocardial infarction Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:  A. Assist the client to use the bedside commode.  B. Administer stool softeners every day as ordered.  C. Administer antidysrhythmics prn as ordered.  D. Maintain the client on strict bed rest. Correct Answer: B. Administer stool softeners every day as ordered. Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the Valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.  Option A: A bedside commode for a client with acute MI should be provided, but it does not prevent Valsalva maneuver alone.  Option C: Antidysrhythmics do not prevent Valsalva maneuver. Antidysrhythmic agents, which are also known as antiarrhythmic agents, are a broad category of medications that help ameliorate the spectrum of cardiac arrhythmias to maintain normal rhythm and conduction in the heart.  Option D: A client with acute MI can be given bathroom privileges with assistance. NCLEXRN-02-058 Question Tag: psychiatric unit Question Category: Safe and Effective Care Environment, Management of Care On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to:  A. Give the client orientation materials and review the unit rules and regulations.  B. Introduce him/her and accompany the client to the client’s room.  C. Take the client to the day room and introduce her to the other clients.  D. Ask the nursing assistant to get the client’s vital signs and complete the admission search. Correct Answer: B. Introduce him/herself and accompany the client to the client’s room. Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.  Option A: The client is still confused and fearful. Orientation should be postponed until he is calm. They can deliver effective, safe care by assessing risk and building a rapport with the patient during the admission process; utilizing crisis prevention strategies, including appropriate medication administration, environmental, psychobiological, counseling, and health teaching interventions; and employing conflict resolution techniques. (trachea) and large airways (bronchi) and is typically used in people who are on mechanical ventilation or have problems with nerves or muscles that make coughing less effective for bringing up secretions.  Option D: Hyperventilation does not produce high pitched wheezes that extend throughout exhalation. The lowered carbon dioxide levels in the blood can cause squeezing of the airways, which then results in wheezing. Hyperventilation syndrome may cause the following chest symptoms like chest pains or tenderness, shortness of breath, and wheezing. NCLEXRN-02-061 Question Tag: domestic abuse Question Category: Psychosocial Integrity Which behavioral characteristic describes the domestic abuser?  A. Alcoholic  B. Overconfident  C. High tolerance for frustrations  D. Low self-esteem Correct Answer: D. Low self-esteem Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self- esteem, and have a great need to exercise control or power-over partners.  Option A: Being an alcoholic predisposes an individual to be a domestic abuser. To be perfectly clear, alcohol and alcoholism are never a sole trigger for, or cause of, domestic abuse. Rather, they are compounding factors that could eventually trigger intimate partner abuse in a violent individual.  Option B: Most domestic abusers have low self-confidence or self-esteem. Basically, domestic violence offenders always feel the need to be in control of their victims. The less in control an offender feels, the more they want to hurt others.  Option C: Domestic abusers often vent out their frustrations on their partners or children. Domestic abuse, often referred to as domestic violence or intimate partner violence (IPV), is a pattern of behavior or behaviors used by one partner to maintain power and control over another partner that they are in a relationship with. Anyone, regardless of race, gender, sexual orientation, religion or age, can be a victim or perpetrator of domestic abuse. Abuse can be physical, sexual, emotional, mental, social and financial. NCLEXRN-02-062 Question Tag: long leg cast Question Category: Health Promotion and Maintenance The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:  A. Isometric  B. Range of motion  C. Aerobic  D. Isotonic Correct Answer: A. Isometric The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part.  Option B: Active range of motion exercises should accompany isometric exercises for every joint that is not immobilized at regular and frequent intervals.  Option C: Aerobic exercise is any type of cardiovascular conditioning and is inappropriate for a client who has a leg cast.  Option D: Isotonic exercise is one method of muscular exercise and it is not recommended for a client who has leg cast. NCLEXRN-02-063 Question Tag: pregnancy Question Category: Physiological Integrity, Reduction of Risk Potential A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?  A. Counsel the woman to consent to HIV screening.  B. Perform tests for sexually transmitted diseases.  C. Discuss her high risk for cervical cancer.  D. Refer the client to a family planning clinic. Correct Answer: A. Counsel the woman to consent to HIV screening The client’s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.  Option B: Before performing the tests, the client should be informed first and she must give her consent. Separate written consent for HIV testing is not recommended. General informed consent for medical care that notifies the patient that an HIV test will be performed unless the patient declines (opt-out screening) should be considered sufficient to encompass informed consent for HIV testing.  Option C: Discussion about the risks can come after determining if the client is HIV positive or not. Increased HIV vulnerability is often associated with legal and social factors, which increases exposure to risk situations and creates barriers to accessing effective, quality and affordable HIV prevention, testing and treatment services.  Option D: Family planning could come after the HIV screening has results. For women with HIV who want to become pregnant, use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV. Afterwards, family planning services that promote healthy timing and spacing of pregnancies are important to reduce the risk of adverse pregnancy outcomes such as low birth weight, preterm birth, and infant mortality. The child in the concrete operational stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.  Option A: Option A describes the preoperational stage. During this stage, young children can think about things symbolically. The preoperational stage is the second stage in Piaget’s theory of cognitive development. This stage begins around age 2, as children start to talk, and lasts until approximately age 7. 1 During this stage, children begin to engage in symbolic play and learn to manipulate symbols.  Option C: In the formal operational stage, people develop the ability to think about abstract concepts, and logically test hypotheses.  Option D: Option D describes the formal operational stage. The formal operational stage begins at approximately age twelve and lasts into adulthood. As adolescents enter this stage, they gain the ability to think in an abstract manner by manipulating ideas in their head, without any dependence on concrete manipulation. NCLEXRN-02-067 Question Tag: depression Question Category: Psychosocial Integrity The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?  A. Nutrition  B. Elimination  C. Activity  D. Safety Correct Answer: D. Safety Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan. Depression can be effectively treated in primary care settings using an evidence-based collaborative approach in which primary care providers are systematically supported by mental health providers in caring for a caseload of patients.  Option A: The client’s nutritional plan can be discussed after his safety has been ensured. Researchers found that a healthy diet (the Mediterranean diet as an example) was associated with a significantly lower risk of developing depressive symptoms.  Option B: Elimination should also be part of the nursing care plan, but this is not the priority. Any psychosocial disturbances can impact on nervous system neuroplasticity and this, in turn, will adversely affect downstream systems including the GIT.  Option C: Activities for a depressed client should be structured and introduced gradually. Teach visualization as a tool to “bring them back down to their bodies” and out of the constant cycle of negative thoughts. Clients learn methods such as the “tree meditation,” in which they imagine themselves as a tree that is growing from the ground and sprouting branches. NCLEXRN-02-068 Question Tag: school-age Question Category: Safe and Effective Care Environment, Safety and Infection Control Which playroom activities should the nurse organize for a small group of 7-year- old hospitalized children?  A. Sports and games with rules.  B. Finger paints and water play.  C. “Dress-up” clothes and props.  D. Chess and television programs Correct Answer: A. Sports and games with rules The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play.  Option B: Finger paints and water play are appropriate play for toddlers. Most toddlers do parallel play. When a child plays alongside or near others but does not play with them this stage is referred to as parallel play.  Option C: Dress-up and props are recommended for preschool. When a child plays together with others and has interest in both the activity and other children involved in playing they are participating in cooperative play.  Option D: Chess is recommended for school-age to adolescent stage. During the school-age years, you’ll see a change in your child. He or she will move from playing alone to having multiple friends and social groups. NCLEXRN-02-069 Question Tag: congestive heart failure Question Category: Health Promotion and Maintenance A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?  A. High Fowler’s  B. Supine  C. Left lateral  D. Low Fowler’s Correct Answer: A. High Fowler’s Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac workload and facilitates breathing.  Option B: Lying flat or in a supine position would be difficult for the client and may induce increased cardiac workload.  Option C: Left lateral position may increase the client’s cardiac workload.  Option D: Low Fowler’s may not be sufficient enough to support the client’s cardiac workload.  Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization NCLEXRN-02-072 Question Tag: migraine Question Category: Health Promotion and Maintenance You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply.  A. Avoid foods that contain tyramine, such as alcohol and aged cheese.  B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.  C. Abortive therapy is aimed at eliminating the pain during the aura.  D. A potential side effect of medications is rebound headache.  E. Complementary therapies such as relaxation may be helpful.  F. Continue taking estrogen as prescribed by your physician. Correct Answer: A, B, C, D, & E. The client should be counseled on the food and drugs that are allowed. He should also be educated about the side effects of the medications given. Methods of distraction from pain should also be included in the teaching plan.  Option A: One explanation is that it causes nerve cells in the brain to release the chemical norepinephrine. Having higher levels of tyramine in the system — along with an unusual level of brain chemicals — can cause changes in the brain that lead to headaches.  Option B: Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines. Dilation of cerebral arteries causes the commonly reported side effect of migraine type headache.  Option C: Abortive therapy should be used as early as possible in the course of a migraine. Combination analgesics containing aspirin, caffeine, and acetaminophen are an effective first-line abortive treatment for migraine. Ibuprofen at standard doses is effective for acute migraine treatment.  Option D: Medication overuse headaches or rebound headaches are caused by regular, long-term use of medication to treat headaches, such as migraines. Pain relievers offer relief for occasional headaches. But if one takes them more than a couple of days a week, they may trigger medication overuse headaches.  Option E: Complementary therapies are add-on therapies meant to be used along with traditional treatment, according to the National Center for Complementary and Integrative Health (NCCIH). Massage, spinal manipulation, and acupuncture are examples of complementary therapies that may be beneficial for people with migraines.  Option F: Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy and menopause, seem to trigger headaches in many women. NCLEXRN-02-073 Question Tag: seizure Question Category: Safe and Effective Care Environment, Management of Care The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?  A. Document the seizure  B. Perform neurologic checks  C. Take the patient’s vital signs  D. Restrain the patient for protection Correct Answer: C. Take the patient’s vital signs. Taking vital signs is within the education and scope of practice for a nursing assistant.  Option A: Documentation is one of the nursing responsibilities.  Option B: The nurse should perform neurologic checks.  Option D: Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision NCLEXRN-02-074 Question Tag: seizure disorder Question Category: Safe and Effective Care Environment, Management of Care You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?  A. Complete admission assessment.  B. Set up oxygen and suction equipment.  C. Place a padded tongue blade at the bedside.  D. Pad the side rails before the patient arrives. Correct Answer: B. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning.  Option A: The RN should perform the complete initial assessment.  Option C: Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins.  Option D: Padded side rails are controversial in terms of whether they actually provide safety and may embarrass the patient and family. NCLEXRN-02-075 Question Tag: epilepsy Question Category: Health Promotion and Maintenance