NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. 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
Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.
2. The priority goal for a family who practices Chinese medicine would be to:
- A. Achieve harmony
- B. Maintain a balance of energy
- C. Respect life
- D. Restore yin and yang
Correct answer: D
Rationale: In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.
3. A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
- A. G4 T1 P0 A1 L2
- B. G3 T1 P0 A1 L2
- C. G3 T0 P1 A1 L2
- D. G4 T0 P1 A1 L2
Correct answer: D
Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history. G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies. T1: She has had one pregnancy that resulted in the birth of her twins at term. P0: She has not had any preterm births. A1: She had one miscarriage at 12 weeks gestation. L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.
4. All of the following are essential components of supervision EXCEPT:
- A. All tasks to be delegated or supervised are within the nurse's scope of practice
- B. The necessary tasks require repeated assessments
- C. The nurse has adequate time to develop staff assignments
- D. Policies have been developed that govern nursing practice
Correct answer: B
Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
5. In which of the following examples would informed consent not be required?
- A. A patient is apprehensive about an upcoming surgery and chooses not to learn of the risks involved with the procedure.
- B. A child is rushed to the Emergency Room after falling from a third-story window.
- C. An adult in a coma in a mental health institution with no listed next of kin.
- D. Informed consent is not required in any of the above examples.
Correct answer: D
Rationale: In emergency situations where immediate treatment is necessary to prevent further harm or save a life, such as in option B where a child is rushed to the Emergency Room after a fall, informed consent may be waived to provide prompt care. In option A, though the patient is apprehensive about surgery and chooses not to learn the risks, informed consent is not required as it is the patient's right to refuse information. In option C, when an adult is in a coma with no next of kin listed, decisions may be made in the patient's best interest following legal and ethical guidelines. Therefore, informed consent is not needed in any of the scenarios presented.
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