Nclex questions and answers for last MC exam Graded A

Nclex questions and answers for last MC exam Graded A A 2-year-old has a tonic-clonic seizure while in the hospital crib. The child's jaws are clamped. Which is the most important nursing action at this time? Select one: a. Place a padded tongue blade between the child's jaws. b. Restrain the child to prevent injury. c. Prepare the suction equipment. d. Stay with the child and observe his respiratory status. - ANS -d. Stay with the child and observe his respiratory status. Rationale: It is important for the nurse to stay with the child to assess for any changes in the child's respiratory status. Place the child in side-lying position, if possible, to allow secretions to drain. Monitor for adequate oxygenation. The child is at risk for hypoxic injury if the respiratory status is compromised. A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which of the following food selections would be most appropriate for his lunch? Select one: A. Fried eggs, bacon, and iced tea B. A hamburger on a bun, French fries, and milk C. A grilled cheese sandwich, potato chips, and a milkshake D. Spaghetti with meatballs, garlic bread, and a cola drink - ANS -A. Fried eggs, bacon, and iced tea Rationale: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal. A child has sustained a traumatic brain injury, and is being monitored in the pediatric intensive care unit. The nurse is using the Glasgow Coma Scale to assess the child. Which assessments will be included? Select all that apply. Select one or more: a. Verbal response b. Head circumference c. Eye opening d. Pulse oximetry e. Motor response - ANS -A,C,E A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which of the following? Select one: A. Syndrome of inappropriate antidiuretic hormone (SIADH) B. Cushing syndrome C. Thyroid storm D. Vitamin D toxicity - ANS -A. Syndrome of inappropriate antidiuretic hormone (SIADH) Rationale: SIADH, although rare in children, is a potential complication of excessive administration of vasopressin. Thyroid storm may result from overadministration of levothyroxine (thyroid hormone replacement). Cushing syndrome is associated with corticosteroid use. Vitamin D toxicity may result from the use of vitamin D as treatment of hypoparathyroidism. A child with growth hormone deficiency is receiving growth hormone. Which of the following would the nurse interpret as indicating effectiveness of this therapy? Select one: A. Rapid weight gain B. Complaints of headaches C. Height increase of 4 inches D. Growth plate closure - ANS -C. Height increase of 4 inches Rationale: Effectiveness of growth hormone therapy is indicated by at least a 3- to 5-inch increase in linear growth in the first year of treatment. Rapid weight gain and headaches are adverse reactions of this therapy. The drug is stopped when the epiphyseal growth plates close. A lumbar puncture is done on an infant suspected to have meningitis. If the infant has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show what result? Select one: a. An elevated red blood cell count b. A decreased white blood cell count c. Normal glucose d. An elevated white blood cell count - ANS -d. An elevated white blood cell count A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see? Select one or more: a. Bulging fontanel b. Positive Babinski sign c. Vomiting d. Loss of coordination or balance e. Redness along the shunt tract - ANS -c. Vomiting Vomiting is a sign of increased intracranial pressure, which is often present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. d. Loss of coordination or balance Loss of coordination or balance is a sign of increased intracranial pressure, which may be present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. e. Redness along the shunt tract Redness along the shunt tract is often present with a shunt infection as a result of the body's response to the infectious agent. A nurse is caring for a hospitalized 3 month old infant admitted following a motor vehicle accident. The child is being monitored for increased intracranial pressure. The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action would the nurse take? Select one: a. Lower the head of the bed b. Have the mother provide comfort measures and reassess. c. Place the infant on NPO status d. Notify the physician immediately - ANS -b. Have the mother provide comfort measures and reassess. Rationale: When an infant cries intercranial pressure increases causing the fontanel to bulge. Since crying can occur because of hunger, thirst, pain, the nurse should attempt to decrease the crying by assessing the cause. Notifying the MD first would result in the MD asking the question, "What have you done to decrease the cause of the cry which is increasing the icp? A nurse is doing a postop assessment on an infant who has just had a ventroperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt? Select one: a. Bulging fontanelle b. Negative Brudzinski sign c. Incisional pain d. Movement of all extremities - ANS -a. Bulging fontanelle A nurse is teaching the parents of an infant with congenital adrenal hyperplasia about the signs and symptoms of adrenal crisis. The nurse determines that the teaching was successful when the parents identify which of the following? Select one: A. Persistent vomiting B. Fluid overload C. Constipation D. Bradycardia - ANS -A. Persistent vomiting Rationale: Signs and symptoms of acute adrenal crisis include persistent vomiting, dehydration, hyponatremia, hyperkalemia, hypotension, tachycardia, and shock.