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Loading... EAQ RN NCLEX Spring 2021

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Quiz: Nursing Diagnosis Correct Answers: 28 

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1. A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less regular intervals, with a scanty flow. What does the nurse conclude is the most likely cause of these changes? 1

Ut er i necancer 2 Lackofes t r ogen 3 Ear l yc er vi calcar ci noma Correct4 Expect edmenopaus al changes

Theadapt at i onsdesc r i bed,al ongwi t ht hecl i ent ' sage,suggestt hatt hec l i enti sexper i enci ngmenopause. I r r egul arspot t i ngandbl eedi ngoccurwi t hut er i necanc erandar enotassoc i at edwi t ht hemens t r ual cycl e. Est r ogeni sr educ ed,notel i mi nat ed,dur i ngandaf t ermenopause;t headr enalgl andspr oduceas mal l amountofest r ogent hr oughoutl i f e.Ear l ycer v i calcanc eri sas ympt omat i c;ani r r egul arbl oodyv agi nal di s char gei sal at es i gnofcer v i calc anc er . Test Taki ngTi p:I dent i f yopt i oncomponent sascor r ectori ncor r ec t .Thi smayhel py oui dent i f yawr ong answer .Exampl e:I fy ouar ebei ngas k edt oi dent i f yadi ett hati sspeci fict oac er t ai nc ondi t i on,your k nowl edgeaboutt hatcondi t i onwoul dhel py ouchoos et hecor r ectr es pons e( e. g. ,c hol ec y s t ect omy=l owf at ,hi ghpr ot ei n,l owc al or i edi et ) . 86%ofst udent snat i onwi deanswer edt hi squest i oncor r ect l y . Vi ewTopi c s 2.

2939924203

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2. A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? 1 Put t i ngbot hl egsi nt r ac t i onk eepsonel egf r om bec omi ngl ongert hant heot her . 2 Put t i ngbot hl egsi nt r ac t i onk eepst hebabyf r om t ur ni ngoveri nbedandbr eaki nghi sl egagai n. Correct3 Asameansofens ur i ngcount er t r act i on,bot hl egsar epl acedi nt r act i on,andt hebut t ocksar es uspended offt hebed.

4 Whent hel egwasx r ay ed,t heheal t hcar epr act i t i onerappar ent l ydi s cov er edt hatt heot herl egwasbr ok en aswel l . I ny oungi nf ant st hebodywei ghtdoesn' tpr ov i deadequat ec ount er t r act i ont oov er comet hes pasm oft he mus cl es .Wi t hbot hl egsi nt r act i onandt hebut t oc kss uspendedofft hebed,count er t r ac t i oni ssuffici entt o r eal i gnt hef emur .Put t i ngbot hl egsi nt r act i ondoesnotk eept hechi l df r om havi ngonel egl ongert hant he ot her .Abedj ack etcoul dk eept hechi l df r om t ur ni ngov eri nbed;k eepi ngt hebabyf r om t ur ni ngov eri n

bedi snott her eas onf orput t i ngbot hl egsi nt r act i on.Thi st y peoft r act i oncanbeusedf oronef r ac t ur ed f emur ;i ti snotr es er v edf orbi l at er al f r ac t ur es . 55%ofst udent snat i onwi deanswer edt hi squest i oncor r ect l y . Vi ewTopi c s 3.

3030816632

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3. A 37-year-old woman is admitted to the unit with severe menorrhagia. During assessment the nurse learns that she has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing the size of the fibroids, without success. The lab reports hemoglobin and hematocrit readings of 6.8 g/dL (68 mmol/l) and 20.2 (20%), respectively. The client begins to sob and cries, "I don’t know what to do— my primary healthcare provider is recommending a hysterectomy, but I haven’t had children yet!" What is the best response by the nurse? 1 " Ther ear es omanychi l dr enupf oradopt i on,l ooki ngf oramot her . " Correct2 " Thi smustbes odi fficul tf ory ou.Chi l dr enar er eal l yi mpor t antt oy ou?"

3 " Your eal l yhav enochoi cebutt of ol l owt her ecommendat i on;t hepr i mar yheal t hcar epr ovi deri sr i ght . " 4 " Bel i evemewhenIt el ly out hatk i dsar es odi ffic ul tt or ai se—you’ r ebet t eroffwi t houtt hem. " Val i dat i ngt hec l i ent ’ sf eel i ngsandi nc l udi nganopenendedquest i onwi l l encour agef ur t herexpr ess i on. Pr evi ouspr obl emsandheal t hcondi t i onscoul dl at erbei ncl udedi nt heconv er s at i ont ohel pt hec l i ent mak et hebestdec i si on.Adopt i oni scer t ai nl yanopt i onf ort hi sper son,butt hi si snotwhats heneedst o hearatt hi st i me.Thi ss t at emental socl os esdowncommuni c at i on.Thecl i entdoeshav eac hoi ce,and t el l i nghert hats hedoesnotc oul dpr ecl udef ur t hercommuni c at i onandc auseangeranddef ensi v eness. T el l i ngt hec l i entt hatshe’ sbet t eroffwi t houtc hi l dr eni snotwhatt hecl i entneedst ohear ,es pec i al l ywhen s hei sf aci nganoper at i ont hatc oul dendherc hanceofgi vi ngbi r t ht ochi l dr en. 94%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 4.

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4. A nurse instills an antibiotic ophthalmic ointment into a newborn’s eyes. What condition does this medication prevent? 1

Her pet i copht hal mi a 2 Ret i nopat hyofpr emat ur i t y Correct3 Opht hal mi aneonat or um

4 Hemor r hagi cconj unct i vi t i s Opht hal mi aneonat or um i scaus edbygonor r healand/ orchl amydi ali nf ec t i onspr esenti nt hev agi nal t r act .I ti spr ev ent abl ewi t ht hepr ophyl act i cus eofanant i bi ot i copht hal mi coi nt mentappl i edt ot he neonat e’ sey es.Her pesaffec t st heneonat es y st emi c al l y .Ret i nopat hyofpr emat ur i t y( f or mer l yr et r ol ent al fi br opl asi a)oc cur sasar es ul tofpr ol ongedexpos ur et oat oohi ghoxy genconcent r at i on.Hemor r hagi c c onj unct i v i t i si sus ual l ycausedbyr api dexpul si onoft hef et us ’ sheadf r om t hev agi na. STUDYTI P:I dent i f yy ourpr obl em ar east hatneedat t ent i on.Donotwas t et i meonr est udy i ngi nf or mat i on y ouk now. 56%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 5.

3030899749

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5. The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1 Al lnur s i ngf unct i onswi l lbec ompl et edbydi s char ge. 2 Al li nvasi v ei nt r av enousl i neswi l lr emai npat ent . 3 Thec l i entwi l lr emai nawak e,al er t ,andor i ent edatal lt i mes . Correct4 Thec l i entwi l lbef r eeofs i gnsands y mpt omsofi nf ec t i onbydi sc har ge.

Whenev eracl i enthasani nf ect i onori satr i s kf ori nf ect i on,t henur se' spr i mar yobj ec t i v ei npr ov i di ngc ar e i st opr ev enti nf ect i onorper f or m act i vi t i est hatwi l lpr omot et hecl i ent ' sbei ngf r eef r om i nf ect i onbyt he t i meofdi s c har ge.Theot herexpec t edout comesar edesi r abl ebutar emor egener ali nnat ur e. 94%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 6.

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6. A nurse is preparing a teaching plan for the parents of a child with celiac disease. What information on the basic problem in celiac disease does the nurse include? 1 Gr eenst ool s Correct2 I nt ol er anceofgl ut en

3 Abs enc eofi nt es t i nalv i l l i 4 Sus cept i bi l i t yt os ev er edehy dr at i on Cel i acdi s easei sani mmunol ogi calsmal li nt est i neent er opat hychar act er i z edbyt hei nabi l i t yt omet abol i ze t hegl i adi ncomponentofgl ut enf oundi ngr ai nss uc haswheat ,bar l ey ,r y e,andoat s ;t hi sr esul t si n ex ces si v egl ut ami net hati st ox i ct ot hemuc os alc el l s.Thest ool sar ef at t yandy el l ow.Thei nt est i nalvi l l i ar epr esentbutwi l lat r ophyi fex pos edt of oodscont ai ni nggl ut en.Fl ui dbal ancei snott hebasi cpr obl em wi t hcel i acdi s ease;howev er ,dehy dr at i onmayocc uri nc el i accr i s i s . 89%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 7.

2939907631

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7. A nurse determines that the client’s apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? 1 Thec l i ent ’ shear tmaybebeat i ngf ast ert empor ar i l y . 2 Thenur semaynotknowhowt ot ak eanacc ur at epul s e. 3 Ther adi al pul s esi t emaybes ur r oundedbyt oomuchsubc ut aneousf at . Correct4 Thec l i entmayhaveat r i alfibr i l l at i on.

r i alfibr i l l at i onhav eapul s edefi ci tcausedbyr educ t i onofpr el oad.Anac cel er at ed Cl i ent swhohav eat hear tr at ei sknownast achy car di a,notapul sedefici t .I ti sunl i kel yt henur s edoesnotknowhowt ot ak ea pul s eac cur at el y ;nur sesar et r ai nedi nas sessment .I fapul s edefi ci ti dent i fiedatapul sesi t ei sat t r i but ed t ot hepr esenc eofex cess i v es ubcut aneousf at ,t henur ses houl dobt ai nt heper i pher al pul seatadi ffer ent s i t e.

Test Taki ngTi p:Neverl eav eaques t i onunans wer ed.Ev eni fans wer i ngi snomor et hananeducat ed guessony ourpar t ,goaheadandmar kanans wer .Youmi ghtber i ght ,buti fyoul eav ei tbl ank,y ouwi l l c er t ai nl ybewr ongandl os epr ec i ouspoi nt s. 67%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 8.

3201609082

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8. The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 Thenur senot esnonv er balsi gnsofdi s comf or t . 2 Thenur seobser v est hec l i ent ’ sposi t i oni nbed. Correct3 Thenur seas kst hec l i entt oex pl ai nt hes ur ger y .

4 Thenur seas kst hec l i entt or at et hes ev er i t yofpai n. Thenur semus tas ses st hecl i ent ’ sk nowl edgeaboutt hes ur ger yt odet er mi nei ft hecl i enti sawar eoft he out comeofsur ger y .Thenur s eobser v esf ornonver bal si gnsofdi s comf or tbec aus esomec l i ent smaynot s t at et hatt heyar ei npai n.Thenur s eobs er v est hec l i ent ’ spos i t i oni ngi nbedt odet er mi neanyabnor mal s i gnss uchasdi s comf or torpai n.Thenur s eask st hecl i entt or at et hesev er i t yofpai nt odet er mi nea nur si ngdi agnosi sofpai nr el at edt oas ur gi calwound. 51%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 9.

3029781897

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9. The mother of a preschool-age child tells the school nurse that her husband is dying of cancer and that she is worried about how her child will cope. As part of their discussion, what does the school nurse include that preschool-age children view death as? 1 Uni v er sal 2

I r r ev er s i bl e Correct3 Af or m ofsl eep

4 Af r i ght eni ngghost hi svi ewedasadepar t ur eorsl eepandasr ev er s i bl e.The Bet weent heagesof3and5y ear sdeat uni v er s al i t yandi r r ever si bi l i t yofdeat har ec onc ept shel dbyc hi l dr enst ar t i ngat8t o9y ear sofage.The ear l ys chool –agechi l dof6or7y ear sper soni fi esdeat h,possi bl yenvi si oni ngi tasaghos t ,ands eesi tas hor r i bl eandf r i ght eni ng;t hi si scons i st entwi t ht heconcr et et hi nki ngpr es entatt hi sage. 81%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 10. 3030119162

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10. The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? 1 Post par t um hemor r hagei sanexpec t edcompl i cat i on. Correct2 Per i nat almor t al i t yi st wot ot hr eet i mesmor el i kel yi nmul t i pl et hani nsi ngl ebi r t hs .

3 Opt i mal ps y chol ogi caladj us t mentaf t eramul t i pl ebi r t hr equi r es6mont hst o1y ear . 4 Mat er nalmor t al i t yi shi gherdur i ngt hepr enat al per i odi nt hes et t i ngofmul t i pl egest at i on. Per i nat almor bi di t yandmor t al i t yr at esar ehi gherwi t hmul t i pl egest at i onpr egnanci es ,becaus et hegr eat er met abol i cdemandsandt hepos si bi l i t yofmal posi t i oni ngofoneormor ef et us esi ncr eas est her i skf or c ompl i c at i ons.Al t houghpos t par t um hemor r hagedoesoc curmor ef r equent l yaf t ermul t i pl ebi r t hs,i ti snot anex pect edoc cur r ence.Adj ust mentt oamul t i pl egest at i onandbi r t hi si ndi v i dual ;t het i meneededf or adj ust mentdoesnotpl acet hepr egnancyathi ghr i sk .Mat er nalmor t al i t ydur i ngt hepr enat alper i odi snot i nc r eas edi nt hepr esenceofamul t i pl eges t at i on. Test Taki ngTi p:Pacey our sel fdur i ngt het est i ngper i odandwor kasacc ur at el yaspos si bl e.Donotbe pr es sur edi nt ofini shi ngear l y .Donotr us h!St udent swhoachi ev ehi ghers cor esonex ami nat i onsar e t y pi cal l yt hosewhouset hei rt i mej udi ci ousl y . 56%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 

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Loading... EAQ RN NCLEX Spring 2021

Quiz Results 

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Quiz: Nursing Diagnosis Correct Answers: 28 « 1 2 3 » 12. 3200879042

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12. Which critical thinking skill does the nurse associate with the concept of maturity? 1 Eager nes st oacqui r eknowl edge 2 Bei ngt ol er antofdi ffer entvi ews 3 T r us ti nownr easoni ngpr ocess es Correct4 Abi l i t yt or eflec tonownj udgment s

Mat ur i t yi st heabi l i t yofacr i t i cal t hi nk ert or efl ec tonhi sorherownj udgment s .Acr i t i calt hi nk err eal i zes t hatmul t i pl esol ut i onsar eaccept abl e.I nqui si t i venes si st heeager nes st oacqui r eknowl edge.Acr i t i cal t hi nk eri sc onsi der edopenmi ndedi fheors her es pect st her i ghtofot her st ohavedi ffer entopi ni onsand i st ol er antofdi ffer entvi ews.Thec r i t i c alt hi nkerposs es sessel f confidenceandt r ust si nhi sorherown r easoni ngpr oces s. 58%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 14. 3029908601

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14. A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse?

Correct1 Thec hi l di st r yi ngt oas ser ti ndependenc e.

2 Thec hi l di seagert or esumer egul arpl ayact i vi t i es. 3 Thec hi l di suns ur eoft hedi ffer enc ebet weeny esandno. 4 Thec hi l di sconf usedasar esul tofi nc r eas edi nt r acr ani alpr ess ur e. Thet oddl eri sexhi bi t i ngt ypi c al behavi orf ort hi sdev el opment all ev el ;mostt oddl er swi l l saynoasa meansofass er t i ngt hei ri ndependence.Al t hought hec hi l dmaybeeagert or es umepl ayi ng,t hebehavi or descr i bedi sr el at edt ot hechi l d' sass er t i onofaut onomy .Al t hought oddl er swhoar eat t empt i ngt oasser t i ndependencewi l lsaynoev enwhent heymeanyes ,t heydounder st andt hedi ffer enc e.Thi sc hi l d' s behavi ordoesnoti ndi c at econf us i on;i ti st y pi cal of2y ear ol dc hi l dr en,whowi l lsaynot omos tt hi ngsas ameansofas ser t i ngt hei ri ndependence. 61%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 15. 3028692746

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15. An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? 1 Regr essi on Correct2 Suppr es si on

3 React i onf or mat i on 4 Pass i v eaggr essi on Suppr es si oni st hev ol unt ar ye xc l usi onf r om awar enes sofanxi et y pr oduci ngf eel i ngs ,i deas ,and s i t uat i ons .I nr egr essi on,aper s onr et ur nst oanear l i erandmor ecomf or t abl edev el opment all ev el . Pass i v eaggr essi oni st heus eofbehav i or ssuc haspas si v i t y ,pr ocr ast i nat i on,andi neffic i enc yt hat negat i v el yaffectot her s.React i onf or mat i oni saconsc i ousbehav i ort hati st heopposi t eofanunconsc i ous f eel i ng. 85%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y .

Vi ewTopi c s 16. 3030171197

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16. A 26-year-old G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks’ gestation. On examination the nurse notes that she has gained 8 lb (3.6 kg) since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? Correct1 Mi l dpr eecl ampsi a

2 Sev er epr eecl ampsi a 3 Chr oni chy per t ensi on 4 Gest at i onal hy per t ensi on Pr eec l amps i ai shyper t ensi ont hatdev el opsaf t er20weeks ’gest at i oni napr ev i ousl ynor mot ensi v e woman.Wi t hmi l dpr eecl ampsi at hes ys t ol i cbl oodpr es sur ei sbel ow160mm Hganddi ast ol i cBPi s bel ow 110mm Hg.Pr ot ei nur i ai spr es ent ,butt her ei snoev i denceofor gandy sf unct i on.Sev er e pr eecl ampsi ai sasy st ol i cbl oodpr essur eofgr eat ert han160mm Hgordi ast ol i cbl oodpr es sur eofat l eas t110mm Hgandpr ot ei nur i aof5gormor eper24hours pec i men.Chr oni chyper t ens i oni s hy per t ens i ont hati spr es entbef or et hepr egnanc yordi agnosedbef or e20week s ’gest at i on.Ges t at i onal hy per t ens i oni st heonsetofhy per t ens i ondur i ngpr egnancywi t houtot hersi gnsors ympt omsof pr eecl ampsi aandwi t houtpr eex i s t i nghyper t ensi on. Test Taki ngTi p:Readc ar ef ul l yandans wert hequest i onas ked;payat t ent i ont os peci fi cdet ai l si nt he quest i on. 73%ofst udent snat i onwi deanswer edt hi squest i oncor r ec t l y . Vi ewTopi c s 17. 3042093544

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17. A client with moderate dementia often assaults nursing staff, and the staff members decide to develop a plan to minimize this behavior. What should the plan include? 1 Li mi t i ngt het i mes t affandt hec l i entspendt oget her 2 Anout l i neoft hec onsequenc esf oruncooper at i v ebehav i or

3 Thec l i ent ’ spr ef er encesf orus easar ewar dorapuni s hment Correct4 I dent i fi cat i onofnur si ngs t affmember swhom t hec l i entpr ...