NCLEX-PN
NCLEX PN Exam Cram
1. A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct answer: A
Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.
2. At what age will vision be 20/20 in children?
- A. 4 years old
- B. 5 years old
- C. 6 years old
- D. 7 years old
Correct answer: C
Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.
3. A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct answer: B
Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.
4. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?
- A. "This diet can be used when there is close medical supervision."?
- B. "This is a long-term treatment measure that assists obese people who can't lose weight."?
- C. "The VLCD consists of solid food items that are pureed to facilitate digestion and absorption."?
- D. "A VLCD contains very little protein."?
Correct answer: A
Rationale: The correct answer is, "This diet can be used when there is close medical supervision."? Very low-calorie diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Choice B is incorrect because VLCDs are typically short-term interventions. Choice C is incorrect because VLCDs usually consist of nutritionally complete liquid formulations, not solid food items that are pureed. Choice D is incorrect because VLCDs actually contain a high quality of protein, although the overall caloric content is very low.
5. A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:
- A. "That varies from client to client."?
- B. "You should discuss that with your physician."?
- C. "You should notice a difference in a few days."?
- D. "It might take several weeks before you notice improvement."?
Correct answer: D
Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.
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