NCLEX-PN
Nclex Questions Management of Care
1. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
- A. Car safety seat in the back seat in a face-forward position
- B. Booster seat with one of the car's seat belts placed over the child
- C. Booster seat in a rear-facing position in the front seat
- D. Car safety seat in a face-forward position in the front seat
Correct answer: B
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
2. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. multiple sclerosis
- D. Huntington's chorea
Correct answer: D
Rationale: Huntington's chorea is characterized by writhing, twisting movements of the face and limbs, known as chorea. This disorder is caused by a genetic mutation affecting specific brain cells. Epilepsy presents with seizures, Parkinson's with tremors and rigidity, and multiple sclerosis with central nervous system issues. The specific description of writhing and twisting movements aligns with Huntington's chorea, making it the correct answer. Choices A, B, and C are incorrect as they describe different neurological disorders with distinct symptoms that do not match the writhing, twisting movements characteristic of Huntington's chorea.
3. The nurse uses prioritization to determine all of the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct answer: C
Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
4. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?
- A. Open the airway.
- B. Administer oxygen.
- C. Suction the client.
- D. Check for breathing.
Correct answer: A
Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.
5. Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct answer: A
Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism. Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.
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