Nclex questions for last MC exam!!!

A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see? Select one or more: a. Bulging fontanel b. Positive Babinski sign c. Vomiting d. Loss of coordination or balance e. Redness along the shunt tract

c. Vomiting Vomiting is a sign of increased intracranial pressure, which is often present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. d. Loss of coordination or balance Loss of coordination or balance is a sign of increased intracranial pressure, which may be present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. e. Redness along the shunt tract Redness along the shunt tract is often present with a shunt infection as a result of the body's response to the infectious agent.

A nurse is doing a postop assessment on an infant who has just had a ventroperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt? Select one: a. Bulging fontanelle b. Negative Brudzinski sign c. Incisional pain d. Movement of all extremities

a. Bulging fontanelle

A young child's parents call the nurse after their child was bitten by a raccoon in the woods. The nurse's recommendation should be based on which of the following? a. Child should be hospitalized for close observation. b. No treatment is necessary if thorough wound cleaning is done. c. Antirabies prophylaxis must be initiated. d. Antirabies prophylaxis must be initiated if clinical manifestations appear.

c. Antirabies prophylaxis must be initiated. Rationale: Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible

A nurse is teaching the parents of an infant with congenital adrenal hyperplasia about the signs and symptoms of adrenal crisis. The nurse determines that the teaching was successful when the parents identify which of the following? Select one: A. Persistent vomiting B. Fluid overload C. Constipation D. Bradycardia

A. Persistent vomiting Rationale: Signs and symptoms of acute adrenal crisis include persistent vomiting, dehydration, hyponatremia, hyperkalemia, hypotension, tachycardia, and shock.

A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which of the following? Select one: A. Syndrome of inappropriate antidiuretic hormone (SIADH) B. Cushing syndrome C. Thyroid storm D. Vitamin D toxicity

A. Syndrome of inappropriate antidiuretic hormone (SIADH) Rationale: SIADH, although rare in children, is a potential complication of excessive administration of vasopressin. Thyroid storm may result from overadministration of levothyroxine (thyroid hormone replacement). Cushing syndrome is associated with corticosteroid use. Vitamin D toxicity may result from the use of vitamin D as treatment of hypoparathyroidism.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as: Select one: A. Confusion B. Obtunded C. Stupor D. Coma

B. Obtunded Rationale: Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli.

A child with growth hormone deficiency is receiving growth hormone. Which of the following would the nurse interpret as indicating effectiveness of this therapy? Select one: A. Rapid weight gain B. Complaints of headaches C. Height increase of 4 inches D. Growth plate closure

C. Height increase of 4 inches Rationale: Effectiveness of growth hormone therapy is indicated by at least a 3- to 5-inch increase in linear growth in the first year of treatment. Rapid weight gain and headaches are adverse reactions of this therapy. The drug is stopped when the epiphyseal growth plates close.

The nurse suspects that a 4-year-old with type 1 diabetes is experiencing hypoglycemia based on which of the following? Select all that apply. Select one or more: A. Diaphoresis B. Blurred vision C. Fruity breath odor D. Slurred speech E. Tachycardia F. Dry, flushed skin

The correct answer is: Diaphoresis, Slurred speech, Tachycardia Rationale: Manifestations of hypoglycemia include behavioral changes, confusion, slurred speech, belligerence, diaphoresis, tremors, palpitation, and tachycardia. Blurred vision; dry, flushed skin; and fruity breath odor suggest hyperglycemia.

What clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure

a. Bulging fontanel and dilated scalp veins Rationale: Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates.

An 8-year-old boy with Duchenne muscular dystrophy is being seen in the clinic for a routine health visit. An appropriate nursing diagnosis for this client would be: Select one: a. Risk for injury related to muscle weakness. b. Risk for impaired skin integrity related to paresthesia to lower extremities. c. Risk for infection related to altered immune system. d. Risk for altered comfort related to effects of muscular dystrophy disease.

a. Risk for injury related to muscle weakness.

The nurse assesses a child and finds that the child's pupils are pinpoint. The nurse interprets this finding as indicating which of the following? a. intracranial mass b. brain stem dysfunction c. seizure activity d. brain stem herniation

b. brain stem dysfunction Rationale: Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use. Dilated but reactive pupils are seen after seizures. Fixed and dilated pupils are associated with brain stem herniation. A single dilated but reactive pupil is associated with an intracranial mass.

Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)? a. DMD is inherited as an autosomal dominant disorder. b. DMD is characterized by weakness of the proximal muscles of both the pelvic and shoulder girdles. c. DMD is characterized by muscle weakness, usually beginning at about age 3 years. d. The onset of DMD occurs in later childhood and adolescence.

c. DMD is characterized by muscle weakness, usually beginning at about age 3 years.

A 2-year-old has a tonic-clonic seizure while in the hospital crib. The child's jaws are clamped. Which is the most important nursing action at this time? Select one: a. Place a padded tongue blade between the child's jaws. b. Restrain the child to prevent injury. c. Prepare the suction equipment. d. Stay with the child and observe his respiratory status.

d. Stay with the child and observe his respiratory status. Rationale: It is important for the nurse to stay with the child to assess for any changes in the child's respiratory status. Place the child in side-lying position, if possible, to allow secretions to drain. Monitor for adequate oxygenation. The child is at risk for hypoxic injury if the respiratory status is compromised.

Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis? Select one: A. Swimming B. Playing basketball C. Jogging every other day D. Using a treadmill

A. Swimming Rationale: Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. Jogging, using a treadmill, and playing basketball would place pressure on the joints of the lower extremities.

Which of the following types of seizures involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

c. Generalized Rationale: Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres.

Which of the following is the initial clinical manifestation of generalized seizures? a. Being confused b. Feeling frightened c. Losing consciousness d. Seeing flashing lights

c. Losing consciousness Rationale: Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation.

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which of the following? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.

d. Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children. Rationale: H. influenzae type b meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely.

A young boy has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which of the following? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.

a. Recommend genetic counseling. Rationale: Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? a. "limit the amount of t.v. he watches" b. "watch for changes in his behavior or eating patterns" c. "call the doctor if he gets a headache." d. "always keep his head raised 30 degrees"

b. "watch for changes in his behavior or eating patterns" rationale: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

A nurse is caring for a hospitalized 3 month old infant admitted following a motor vehicle accident. The child is being monitored for increased intracranial pressure. The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action would the nurse take? Select one: a. Lower the head of the bed b. Have the mother provide comfort measures and reassess. c. Place the infant on NPO status d. Notify the physician immediately

b. Have the mother provide comfort measures and reassess. Rationale: When an infant cries intercranial pressure increases causing the fontanel to bulge. Since crying can occur because of hunger, thirst, pain, the nurse should attempt to decrease the crying by assessing the cause. Notifying the MD first would result in the MD asking the question, "What have you done to decrease the cause of the cry which is increasing the icp?

A lumbar puncture is done on an infant suspected to have meningitis. If the infant has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show what result? Select one: a. An elevated red blood cell count b. A decreased white blood cell count c. Normal glucose d. An elevated white blood cell count

d. An elevated white blood cell count

Which of the following may be beneficial in reducing the risk of Reye syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza

d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza Rationale: Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided.

The nurse should recommend medical attention if a child with a slight head injury experiences which of the following? a. Sleepiness b. Vomiting, even once c. Headache, even if slight d. Confusion or abnormal behavior

d. Confusion or abnormal behavior Rationale: Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait.

A child has sustained a traumatic brain injury, and is being monitored in the pediatric intensive care unit. The nurse is using the Glasgow Coma Scale to assess the child. Which assessments will be included? Select all that apply. Select one or more: a. Verbal response b. Head circumference c. Eye opening d. Pulse oximetry e. Motor response

A,C,E

The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What would be the nurse's best intervention in this case? Select one: A. Ask the parents if they have changed the child's schedule to a less active one. B. Schedule a full evaluation since this may indicate a neurologic disorder. C. Note the regression in the child's chart and recheck in another month. D. Document the findings as a developmental delay since this is a normal occurrence.

The correct answer is: Schedule a full evaluation since this may indicate a neurologic disorder. Rationale: Any child who "loses" a developmental milestone—for example, the child able to sit without support who now cannot—needs an immediate full evaluation, since this indicates a significant neurologic problem.

When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised that a week ago the child had recovered from which of the following? a. Measles b. Varicella c. Meningitis d. Hepatitis

b. Varicella Rationale: Most cases of Reye syndrome follow a common viral illness such as varicella or influenza.

The nurse is caring for a child with severe head trauma after a car accident. Which of the following is an ominous sign that often precedes death? a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing

d. Periodic and irregular breathing Rationale: Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea.

The nurse is planning care for a school-age child with bacterial meningitis. Which of the following should be included? Select one: a. Avoid giving pain medications that could dull sensorium. b. Measure head circumference to assess developing complications. c. Keep environmental stimuli at a minimum. d. Have the child move her head from side to side at least once every 2 hours.

c. Keep environmental stimuli at a minimum.

The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. Which of the following would the nurse interpret as indicative of graft-versus-host disease? Select one: A. Chronic or recurrent diarrhea B. Maculopapular rash C. Splenomegaly D. Presence of wheezing

B. Maculopapular rash Rationale: The nurse should monitor the stem cell transplant child closely for a maculopapular rash that usually starts on the palms and soles for indication that graft-versus-host disease is developing. Wheezing and recurrent diarrhea are not typical clinical manifestations of graft-versus-host disease. Splenomegaly is associated with hypogammaglobulinemia.

The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse knows that parents need further teaching when they state: Select one: a. "We'll watch for any swelling of the feet while the casts are on." b. "We're happy this is the only cast our baby will need." c. "We'll keep the casts dry." d. "We're getting a special car seat to accommodate the casts."

b. "We're happy this is the only cast our baby will need."

A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which of the following food selections would be most appropriate for his lunch? Select one: A. Fried eggs, bacon, and iced tea B. A hamburger on a bun, French fries, and milk C. A grilled cheese sandwich, potato chips, and a milkshake D. Spaghetti with meatballs, garlic bread, and a cola drink

A. Fried eggs, bacon, and iced tea Rationale: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal.

Which of the following best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children.

a. Diagnosis is usually made after metastasis occurs. Rationale: Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as which of the following? a. Eye trauma b. Neurosurgical emergency c. Severe brainstem damage d. Indication of brain death

b. Neurosurgical emergency Rationale: The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding.

An infant has been diagnosed with Osteogenesis Imperfecta. (OI). The nurse is teaching the parents about how to care for their infant. What information is most important for the nurse to include in the instructions to the parents? Select one: a. Notify the health-care provider if your infant does not respond to sound because the infant's central nervous system fails to develop completely. b. If you note signs of infection bring your infant to the clinic because the infant has a significant immune dysfunction. c. Protect your infant from injury and handle your baby carefully because your infant's bones can break very easily d. Check the color of your infant's nail beds and mucous membranes for the signs of circulatory impairment

c. Protect your infant from injury and handle your baby carefully because your infant's bones can break very easily Rationale: OI is also known as brittle bone disease and the infant should be handled carefully and protected from injury.