NCLEX-RN Practice Test 15
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
Koplik's spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Option B: The body rash typically begins on the face and travels downward. Option C: High fever is often present. Option D: "Teardrop on a rose petal" refers to the lesions found in varicella (chickenpox).
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?
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. Options A, B, and C are not part of the routine adolescent exam.
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?
The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Options A, B, and D: These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.
A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is NOT recommended?
A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.
A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission?
Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Options A, C, and D: Hepatitis B, C, and D are transmitted through infected bodily fluids.
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?
Patients with the peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Option B: Fluid overload is not characteristic of PVD. Option C: There is nothing to indicate a psychiatric disturbance in the patient. Option D: Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Options A and B: Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Option C: Transfusion of red cells is indicated for severe anemia.
A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?
Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Option A: Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Option B: Heating pads can cause injury, which can also increase the risk of infection. Option D: Skin lesions at risk for infection should be examined and treated by a physician.
A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?
Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Options A and C: A patient with pulmonary embolism will not be sleepy or have a cough with crackles on the exam. Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia.