during a well baby check of a 6 month old infant the nurse notes abrasions and petechaie of the palate the nurse should
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

2. The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:

Correct answer: D

Rationale: The correct answer is to try to make the client as comfortable as possible but refuse to assist in death. According to the Code of Ethics for Nurses, nurses are committed to providing compassionate care, respecting the dignity and rights of the dying person. In this situation, it is important for the nurse to focus on providing comfort and support to the client while upholding ethical standards. Choice A is incorrect because discussing advance directives does not address the immediate request for assistance in dying. Choice B is incorrect as it does not address the ethical dilemma presented. Choice C is incorrect because instructing the client that only a physician can assist in suicide does not fully address the complexity of the situation or the nurse's role in providing end-of-life care.

3. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug might be absorbed. This process is known as:

Correct answer: C

Rationale: The correct answer is 'enterohepatic cycling.' This process involves drugs being excreted into bile, delivered to the intestines, reabsorbed into the circulation, and can prolong the drug's presence in the body. 'Hepatic clearance' (Choice A) refers to the amount of drug eliminated by the liver. 'Total clearance' (Choice B) is the sum of all types of clearance including renal, hepatic, and respiratory. 'First-pass effect' (Choice D) is the amount of drug absorbed from the GI tract and metabolized by the liver before entering circulation, reducing the amount of drug available for systemic circulation.

4. When helping a client gain insight into anxiety, the nurse should:

Correct answer: B

Rationale: When assisting a client in gaining insight into anxiety, it is crucial to explore the events that lead to increased anxiety. By asking the client to describe these events, the nurse can help the client recognize patterns and triggers, leading to a better understanding of their anxiety. Option A is incorrect because it refers to triggers rather than exploring the events leading to anxiety. Option C is incorrect as it focuses on relaxation techniques rather than delving into the root causes of anxiety. Option D is inappropriate as addressing resistive behavior may not foster a supportive therapeutic environment for the client.

5. A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that

Correct answer: B

Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.

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