NCLEX Practice Exam 5

Question 1

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

Accepted Answer

Examine the tongue

Answer

Vitamin B12 deficiency, often associated with pernicious anemia, commonly manifests as glossitis. This condition causes the tongue to appear smooth, beefy red, and sore due to the atrophy of the papillae. Therefore, examining the tongue is a crucial part of the physical assessment for this client.

Question 2

The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?

Accepted Answer

Reed-Sternberg cells.

Answer

Reed-Sternberg cells are large, distinctive abnormal lymphocytes that are considered the pathological hallmark of Hodgkin's lymphoma. Their presence in a lymph node biopsy is essential for a definitive diagnosis of Hodgkin's disease. Pathologists specifically look for these cells to confirm the diagnosis.

Question 3

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

Accepted Answer

Start O2

Answer

In sickle cell crisis, the primary problem is vaso-occlusion and tissue hypoxia caused by sickled red blood cells. Hypoxia further exacerbates sickling, creating a dangerous cycle. Administering oxygen first is crucial to improve tissue oxygenation, reduce sickling, and alleviate the severe pain, making it the immediate priority intervention.

Question 4

An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

Accepted Answer

Roof of the mouth

Answer

Jaundice, a yellow discoloration, can be challenging to detect in individuals with darker skin tones. The roof of the mouth (hard palate) is a mucous membrane that typically has less pigmentation than the skin. This makes it a more reliable and accurate site for assessing the yellowish tint indicative of jaundice.

Question 5

An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

Accepted Answer

The soles of the feet

Answer

Petechiae, which are tiny pinpoint hemorrhages, can be difficult to visualize on darker skin. The soles of the feet, along with the palms of the hands and mucous membranes, are areas where the skin is naturally lighter and less pigmented. This allows for easier and more accurate detection of petechiae in African American clients.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Practice Exam 5