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NCLEX- RN Practice Exam 4 (PM)
1. A child is admitted to the hospital with a diagnosis of Wilm’s tumor, stage II. Which of the following statements most accurately describes this stage?
- The tumor is less than 3 cm. in size and requires no chemotherapy.
- The tumor did not extend beyond the kidney and was completely resected.
- The tumor extended beyond the kidney but was completely resected.
- The tumor has spread into the abdominal cavity and cannot be resected.
2. A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct.
- Urine specific gravity of 1.040.
- Urine output of 350 ml in 24 hours.
- Brown (“tea-colored”) urine.
- Generalized edema.
3. Which of the following conditions most commonly causes acute glomerulonephritis?
- A congenital condition leading to renal dysfunction.
- Prior infection with group A Streptococcus within the past 10-14 days.
- Viral infection of the glomeruli.
- Nephrotic syndrome.
4. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
- Massaging the groin area twice a day until the fluid is gone.
- Referral to a surgeon for repair.
- No treatment is necessary; the fluid is reabsorbing normally.
- Keeping the infant in a flat, supine position until the fluid is gone.
5. A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
- Inadequate tissue perfusion leading to nerve damage.
- Fluid overload leading to compression of nerve tissue.
- Sensation distortion due to psychiatric disturbance.
- Inflammation of the skin on the hands and feet.
6. A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
- Family history of heart disease.
7. Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct?
- It results when oxygen demand is greater than oxygen supply.
- It is characterized by pain that often occurs duing rest.
- It is a result of tissue hypoxia.
- It is characterized by cramping and weakness.
8. A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?
- Walk barefoot whenever possible.
- Use a heating pad to keep feet warm.
- Avoid crossing the legs.
- Use antibacterial ointment to treat skin lesions at risk of infection.
9. A patient who has been diagnosed with vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
- An adolescent male.
- An elderly woman.
- A young woman.
- An elderly man.
10. A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
- Myocardial infarction due to a history of atherosclerosis.
- Pulmonary embolism due to deep vein thrombosis (DVT).
- Anxiety attack due to worries about her baby’s health.
- Congestive heart failure due to fluid overload.
11. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
- Air embolus.
- Cerebral hemorrhage.
- Expansion of the clot.
- Resolution of the clot.
12. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- Torticollis, with shortening of the sternocleidomastoid muscle.
- Craniosynostosis, with premature closure of the cranial sutures.
- Plagiocephaly, with flattening of one side of the head.
- Hydrocephalus, with increased head size.
13. An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
- The condition was caused by the student’s competitive swimming schedule.
- The student will most likely require surgical intervention.
- The student experiences pain in the inferior aspect of the knee.
- The student is trying to avoid participation in physical education.
14. The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- Spinal flexibility.
- Leg length disparity.
- Hypostatic blood pressure.
15. A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?
- Low self-esteem.
- Self-blame for the injury to the child.
- Single status.
16. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
- The child has a poor chance of recovery without joint deformity.
- Most children progress to adult rheumatoid arthritis.
- Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
- Physical activity should be minimized.
17. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
- The admission orders are written.
- A blood culture is drawn.
- A complete blood count with differential is drawn.
- The parents arrive.
18. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?
- Possible fracture of the tibia.
- Bruising of the gastrocnemius muscle.
- Possible fracture of the radius.
- No anatomic injury, the child wants his mother to carry him.
19. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.
- Regular developmental screening is important to avoid secondary developmental delays.
- Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- Developmental milestones may be slightly delayed but usually will require no additional intervention.
- Parent support groups are helpful for sharing strategies and managing health care issues.
20. A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
- Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
- Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
- Each child has a 1 in 4 (25%) chance of developing the disorder.
- Sons only have a 1 in 4 (25%) chance of developing the disorder.
21. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- Verify patency of the line by the presence of a blood return at regular intervals.
- Inspect the insertion site for swelling, erythema, or drainage.
- Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- If unable to aspirate blood, reposition the client and encourage the client to cough.
- Contact the health care provider about verifying placement if the status is questionable.
22. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.
- Lability of mood
- Ritualistic behavior
- psychomotor retardation
- Self-destructive behavior
23. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.
- The client functions well in other areas of his life.
- The degree of aggressiveness is out of proportion to the stressor.
- The violent behavior is most often justified by the stressor.
- The client has a history of parental alcoholism and chaotic, abusive family life.
- The client has no remorse about the inability to control his anger.
24. Which of the following nursing interventions are written correctly? (Select all that apply.)
- Apply continuous passive motion machine during day.
- Perform neurovascular checks.
- Elevate head of bed 30 degrees before meals.
- Change dressing once a shift.
25. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)
- Place the client in good body alignment
- Check the level of the drainage bag
- Contact the physician
- Check the peritoneal dialysis system for kinks
- Reposition the client to his or her side.
26. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.
- Excess Fluid Volume
- Imbalanced Nutrition; Less than Body Requirements
- Activity Intolerance
- Impaired Gas Exchange
27. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.
- Head tilt
- Increased appetite
- Increased pulse
28. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
- Elevate the HOB to 90 degrees
- Loosen constrictive clothing
- Use a fan to reduce diaphoresis
- Assess for bladder distention and bowel impaction
- Administer antihypertensive medication
- Place the client in a supine position with legs elevated
29. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”
- “I can place an aspirin tablet in my pouch to decrease odor.”
- “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
- “I must use a skin barrier to protect my skin from urine.”
- “I should empty my ostomy pouch of urine when it is full.”
30. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.
- Uterine enlargement
- Fetal heart rate detected by nonelectric device
- Outline of the fetus via radiography or ultrasound
- Chadwick’s sign
- Braxton Hicks contractions
Answers and Rationales
- C. The tumor extended beyond the kidney but was completely resected. The staging of Wilm’s tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
- A. Urine specific gravity of 1.040, B. Urine output of 350 ml in 24 hours. , and C. Brown (“tea-colored”) urine. Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea colored” urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.
- B. Prior infection with group A Streptococcus within the past 10-14 days. Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
- C. No treatment is necessary; the fluid is reabsorbing normally. A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.
- A. Inadequate tissue perfusion leading to nerve damage. Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.
- A. Family history of heart disease. Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor.
- A. It results when oxygen demand is greater than oxygen supply, C. It is a result of tissue hypoxia, and D. It is characterized by cramping and weakness. Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.
- C. Avoid crossing the legs. Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.
- C. A young woman. Raynaud’s disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.
- B. Pulmonary embolism due to deep vein thrombosis (DVT). In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.
- B. Cerebral hemorrhage. Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.
- A. Torticollis, with shortening of the sternocleidomastoid muscle. In torticollis, the sternocleidomastoid muscle is contracted, limiting range of motion of the neck and causing the chin to point to the opposing side. In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size.
- C. The student experiences pain in the inferior aspect of the knee. Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.
- D. Scoliosis. A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Choices A, B, and C are not part of the routine adolescent exam.
- C. Self-blame for the injury to the child. The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.
- C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy.
- B. A blood culture is drawn. Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.
- A. Possible fracture of the tibia. The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.
- A.Regular developmental screening is important to avoid secondary developmental delays , B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties, D. Parent support groups are helpful for sharing strategies and managing health care issues. Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.
- A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. The recessive Duchenne’s gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
- A, B, D, E. A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
- A, B, E.
- A, B, D. A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
- C. It is specific in what to do and when.
- A, B, D, E. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.
- A, B, C. Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.
- A, B, D. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.
- A, B, D, E. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.
- C, D. The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.
- A, D, E, and F. The probable signs of pregnancy include:
- Uterine Enlargement
- Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6.
- Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month
- Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6.
- Ballottement or rebounding of the fetus against the examiner’s fingers of palpation
- Braxton-Hicks contractions
- Positive pregnancy test measuring for hCG.
Positive signs of pregnancy include:
- Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks
- Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG
- Active fetal movement palpable by the examiners
- Outline of the fetus via radiography or ultrasound