a nurse assisting with data collection is preparing to assess the optic nerve the nurse performs this examination by using which technique
Logo

Nursing Elites

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

2. When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?

Correct answer: D

Rationale: When obtaining a health history on a menopausal woman, unexplained vaginal bleeding should be recognized as a contraindication for hormone replacement therapy. This is because it can be a sign of underlying issues that need to be addressed before starting hormone therapy. A family history of stroke is not a contraindication for hormone replacement therapy unless the woman herself has a history of stroke or blood-clotting events. Ovaries removed before age 45 is not a contraindication for hormone replacement therapy. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy; therefore, they are not contraindications.

3. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?

Correct answer: B

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

4. When discussing birth control methods with a client, what major factor should a nurse focus on to provide the motivation needed for consistent implementation of a birth control method?

Correct answer: A

Rationale: When discussing birth control methods with a client, a nurse should focus on the client's personal preference as a major factor that will provide the motivation needed for consistent implementation of a birth control method. Personal preference plays a key role in ensuring that the chosen method aligns with the client's lifestyle and values, increasing the likelihood of adherence. While work and home schedules, family planning goals, and the desire to have children in the future can influence the choice of birth control method, they are not the primary motivating factors for consistent implementation. Personal preference is crucial as it empowers the client to select a method that suits their individual needs and preferences, ultimately leading to better compliance and effectiveness.

5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

Correct answer: D

Rationale: The correct answer is sodium chloride. Duodenal intestinal fluid is rich in potassium (K+), sodium (Na+), and bicarbonate. When suctioning is used to remove excess fluids due to ileus, it results in the loss of sodium chloride (NaCl) leading to decreased sodium (Na+) levels. Choices A, B, and C are incorrect because calcium, magnesium, and potassium are not typically lost in significant amounts through intestinal tube suction in the context of treating ileus.

Similar Questions

A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses