NCLEX-RN Practice Questions (1)

Answer D is correct. The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect.

Rationale: A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. Creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.

Test-Taking Strategy: Focus on the surgical procedure and the subject of the question. The subject of the question relates to the potential for bleeding. Options 1 and 4 can be eliminated because they relate to kidney function. Similarly, option 3 can be eliminated because it is unrelated to the subject of the question. Review preoperative care of the child scheduled for tonsillectomy if you had difficulty with this question.

Rationale: A tonsillectomy is the surgical removal of the tonsils. Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding.

Test-Taking Strategy: Use the concepts related to the signs of shock to assist in answering this question. These concepts should assist in eliminating options 2 and 4. From the remaining options, recalling that discomfort is expected and does not indicate bleeding will direct you to option 1. Review the signs of bleeding after tonsillectomy if you had difficulty with this question.

Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child’s condition is improving. Warm, dry skin indicates an improvement in the child’s condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal respiratory rate in a 10- year-old is 16 to 20 breaths/min.

Rationale: Sudden infant death syndrome (SIDS) is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fails to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position.

Rationale: Congestive heart failure (CHF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with CHF, but is not an early sign.

Test-Taking Strategy: Note the strategic word early. Think about the physiology and the effects on the heart when fluid overload occurs. These concepts will assist in directing you to option 3. If you had difficulty with this question, review the early signs of CHF in an infant.

Rationale: Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, subcutaneous tissues, and blood vessels of the central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help to confirm the diagnosis of rheumatic fever.

Test-Taking Strategy: Use the process of elimination. Recalling that rheumatic fever characteristically is associated with streptococcal infection will direct you to option 4. If you had difficulty with this question, review the Jones criteria and diagnostic tests for rheumatic fever.

Rationale: Kawasaki disease is also known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

Test-Taking Strategy: Use the process of elimination. Option  2 can be eliminated first because a normal appearance is not likely in the acute stage. From the remaining options, focusing on the strategic words acute stage in the question will assist in directing you to option 3. Review the clinical manifestations associated with each stage of Kawasaki disease if you had difficulty with this question.

Rationale: Congestive heart failure (CHF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

Test-Taking Strategy: Use the process of elimination. Recall the situations that would place stress and an increased workload on the heart; this should direct you to option 4. Drawing blood is an invasive procedure, which would likely cause the infant to cry. Review care of a child with CHF if you had difficulty with this question.

Rationale: Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly–like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.

Test-Taking Strategy: Focus on the diagnosis and think about the pathophysiology that occurs. Recalling that a classic manifestation is currant jelly–like stools will assist in directing you to option 4. Review the manifestations of intussusception if you had difficulty with this question.

Answer: A. Juxtaglomerular cells in the kidneys secrete renin in
response to low blood flow or a low sodium level. The eventual
effect of renin secretion is an increase in blood pressure