the nurse is assisting with data collection on a well baby examination the nurse measures the head circumference and it is the same as the chest circu
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Nursing Elites

NCLEX-PN

2024 PN NCLEX Questions

1. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

2. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

3. A healthcare provider is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the healthcare provider first place an activated tuning fork?

Correct answer: C

Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. Placing the tuning fork on the teeth (Choice A), forehead (Choice B), or the midline of the skull (Choice D) is not part of the Rinne test procedure. Therefore, the correct answer is to first place the activated tuning fork on the client's mastoid bone.

4. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

5. During the health screening of an adolescent, which finding by the nurse requires further teaching?

Correct answer: B

Rationale: The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.

Similar Questions

Which of the following statements is correct about Maslow's hierarchy of needs?
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
What causes an older female client's hair to turn gray?
A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?
While assisting with data collection regarding the neurological system, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

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