while assisting with data collection the nurse asks the client to close the jaws tightly after which the nurse tries to open the closed jaws in this t
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Nursing Elites

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

2. An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?

Correct answer: D

Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.

3. How should a client's neck be positioned for palpation of the thyroid?

Correct answer: A

Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.

4. Which of the following statements is correct about Maslow's hierarchy of needs?

Correct answer: C

Rationale: The correct statement about Maslow's hierarchy of needs is that two of the levels may require physical intervention while four of the levels may require psychosocial intervention. Maslow's theory suggests that physiological and safety needs are more basic and may require physical interventions, while social, esteem, and self-actualization needs are more psychosocial. Choices A and B are incorrect as they wrongly suggest that all levels may require only one type of intervention. Choice D is incorrect because it inaccurately represents the balance of physical and psychosocial interventions in Maslow's hierarchy of needs.

5. A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction?

Correct answer: C

Rationale: The correct answer is 'Devices that apply pressure alone are available over the counter.' Acupressure over the Neiguan acupuncture point can be used as a complementary alternative therapy to relieve nausea during pregnancy. It can be performed with devices that apply pressure alone, which are available over the counter. Acupressure devices that apply electrical impulses over this point require a prescription. It is not safe to try any type of complementary alternative therapy during pregnancy, as some may be harmful to the mother and fetus. Therefore, the nurse should instruct the client about the availability of over-the-counter pressure devices for acupressure, which are generally safe to use.

Similar Questions

Which of the following is an example of an extended care facility?
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?
Which of the following is least appropriate when caring for a stable postpartum client?
What is the primary theory that explains a family's concept of health and illness?
A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?

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