NCLEX-PN
Quizlet NCLEX PN 2023
1. In Parkinson's disease, a client's difficulty in performing voluntary movements is known as:
- A. Akinesia.
- B. Dyskinesia.
- C. Chorea.
- D. Dystonia.
Correct answer: C.
Rationale: In Parkinson's disease, the client's difficulty in performing voluntary movements is termed dyskinesia. Dyskinesia refers to the impairment of the ability to execute voluntary muscle movements. Akinesia, on the other hand, refers to the absence or lack of voluntary movement. Chorea is characterized by involuntary, rapid, irregular movements. Dystonia involves sustained muscle contractions resulting in abnormal postures or twisting movements. Therefore, dyskinesia is the specific term used for the described difficulty in Parkinson's disease.
2. When administering intravenous electrolyte solution, which of the following precautions should the nurse take?
- A. Infuse hypertonic solutions cautiously.
- B. Mix no more than 60 mEq of potassium per liter of fluid.
- C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
- D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.
Correct answer: C
Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.
3. A 93-year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
- A. Recommend the patient remain in her room at all times.
- B. Recommend family members bring pictures to the patient's room.
- C. Recommend a speech therapy consult to the doctor.
- D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct answer: B
Rationale: For a 93-year-old female with Alzheimer's Disease exhibiting signs of increased confusion and limited stability with gait, recommending family members to bring pictures to the patient's room is the most appropriate course of action. Visual stimulation in the form of pictures may help decrease signs of confusion and provide comfort to the patient. Option A is incorrect as isolating the patient in her room at all times may worsen her condition by further limiting stimulation and interaction. Option C is incorrect as speech therapy may not directly address the current issues of confusion and gait instability. Option D is incorrect as pushing a wheelchair may not be safe for the patient if she is refusing to use it, potentially leading to falls or further distress.
4. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?
- A. Contact the patient's physician immediately.
- B. Check the intake and output on the patient's flow sheet.
- C. Encourage the patient to ambulate to reduce lower extremity edema.
- D. Check the patient's vitals every 2 hours.
Correct answer: B
Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient's flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.
5. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in a right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct answer: D
Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
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