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NCLEX-RN Exam Questions - Part 81
1. A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss.Identify the number-one priority nursing diagnosis.
A) Fluid volume deficit
B) Altered nutrition
C) Altered bowel elimination
D) Anxiety
2. A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
3. Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
A) Cutting, pasting, string beads, music, dolls
B) Mobiles, rattle, squeeze toys
C) Pull-toys, large ball, dolls, sand and water play, music
D) Simple card games, puzzles, bicycle, television
4. A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
A) Books with colorful pictures
B) Music
C) Riding toys
D) Puppets
5. During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the childs change in behavior?
A) Deep-seated feelings of hostility
B) A lack of interest in socializing
C) Usual behavior for this child
D) A coping response
A) Fluid volume deficit
B) Altered nutrition
C) Altered bowel elimination
D) Anxiety
2. A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
3. Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
A) Cutting, pasting, string beads, music, dolls
B) Mobiles, rattle, squeeze toys
C) Pull-toys, large ball, dolls, sand and water play, music
D) Simple card games, puzzles, bicycle, television
4. A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
A) Books with colorful pictures
B) Music
C) Riding toys
D) Puppets
5. During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the childs change in behavior?
A) Deep-seated feelings of hostility
B) A lack of interest in socializing
C) Usual behavior for this child
D) A coping response
1. Right Answer: A
Explanation: (A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening.Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status. (C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.
2. Right Answer: D
Explanation: (A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
3. Right Answer: C
Explanation: (A) These activities are suited for the preschool-age child (35 years old). The activities are not safe for a toddler. (B) Infants (01 year) like these toys. (C) These activities provide the toddler (13 years old) with a variety of physical activities for play. (D) The toddler lacks the physical and cognitive abilities for these activities.The tasks are far better suited for the school-age child.
4. Right Answer: D
Explanation: (A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity.(C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
5. Right Answer: D
Explanation: (A) Unusually aggressive behavior does not indicate a deepseated problem. (B) A lack of social interest results in poor participation in play activities with peers.Aggression would not be an expected behavior. (C) The aggressive behavior was newly developed and not a routine behavior. (D) Play provides the child with opportunities for coping and adaptation. Aggression during the play activities would indicate a coping response.
Explanation: (A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening.Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status. (C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.
2. Right Answer: D
Explanation: (A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
3. Right Answer: C
Explanation: (A) These activities are suited for the preschool-age child (35 years old). The activities are not safe for a toddler. (B) Infants (01 year) like these toys. (C) These activities provide the toddler (13 years old) with a variety of physical activities for play. (D) The toddler lacks the physical and cognitive abilities for these activities.The tasks are far better suited for the school-age child.
4. Right Answer: D
Explanation: (A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity.(C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
5. Right Answer: D
Explanation: (A) Unusually aggressive behavior does not indicate a deepseated problem. (B) A lack of social interest results in poor participation in play activities with peers.Aggression would not be an expected behavior. (C) The aggressive behavior was newly developed and not a routine behavior. (D) Play provides the child with opportunities for coping and adaptation. Aggression during the play activities would indicate a coping response.
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