NCLEX-PN Test #2 3

Question 1

A 4-year-old child is admitted with suspected epiglottitis. Which nursing action is the highest priority?

Accepted Answer

Keep the child calm and do not attempt to visualize the throat

Answer

In epiglottitis, any stimulation (including throat examination) can cause complete airway obstruction. The priority is to keep the child calm and upright (sniffing position) and avoid throat visualization or throat culture until the airway is secured by an experienced provider.

Question 2

The PN is reviewing discharge teaching for a child with a new diagnosis of type 1 diabetes. Which statement by the parent indicates a need for further teaching?

Accepted Answer

"If my child is sick and not eating, I should skip the insulin dose."

Answer

Insulin must NOT be skipped during illness. Stress hormones released during illness raise blood glucose levels, often requiring the same or increased insulin doses. The rule is "sick day management" — check glucose more frequently and follow the provider's sick-day protocol.

Question 3

A client with major depressive disorder says, "I've decided to give away my most prized possessions." How should the PN respond?

Accepted Answer

Notify the charge nurse immediately and implement suicide precautions

Answer

Giving away prized possessions is a classic warning sign of suicidal intent (saying goodbye). This requires immediate action — notify the charge nurse and implement suicide precautions. Engaging in casual conversation or only documenting without action puts the client at serious risk.

Question 4

A 2-year-old is admitted with a febrile seizure. After the seizure, what is the priority nursing assessment?

Accepted Answer

Assess pupillary response and level of consciousness

Answer

After any seizure, airway, breathing, and neurological status are the immediate priorities. Assessing the level of consciousness and pupillary response identifies postictal state and any neurological changes. Temperature is also important but neurological assessment takes priority in the immediate post-seizure period.

Question 5

A client with schizophrenia tells the PN, "The television is sending me secret messages about my mission." The nurse recognizes this as:

Accepted Answer

Idea of reference

Answer

An idea of reference is a type of delusion in which the client believes that external events (such as a TV broadcast) have special personal meaning directed at them. This is distinct from auditory hallucinations (hearing voices) and is a positive symptom of schizophrenia.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #2 3