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NCLEX-PN Exam Questions - Part 9
1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The clients weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
A) within normal limits, so a weight-reduction diet is unnecessary.
B) lower than normal, so education about nutrient-dense foods is needed.
C) indicating obesity because the BMI is 35.
D) indicating overweight status because the BMI is 27.
2. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
A) open leg fracture
B) open head injury
C) stab wound to the chest
D) traumatic amputation of a thumb
3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
A) The clothing is the property of another and must be treated with care.
B) Such care facilitates repair and salvage of the clothing.
C) The clothing of a trauma victim is potential evidence with legal implications.
D) Such care decreases trauma to the family members receiving the clothing.
4. Which of the following terms refers to soft-tissue injury caused by blunt force?
A) contusion
B) strain
C) sprain
D) dislocation
5. A client with dumping syndrome should ___________ while a client with GERD should ___________.
A) sit up 1 hour after meals; lie flat 30 minutes after meals
B) lie down 1 hour after eating; sit up at least 30 minutes after eating
C) sit up after meals; sit up after meals
D) lie down after meals; lie down after meals
A) within normal limits, so a weight-reduction diet is unnecessary.
B) lower than normal, so education about nutrient-dense foods is needed.
C) indicating obesity because the BMI is 35.
D) indicating overweight status because the BMI is 27.
2. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
A) open leg fracture
B) open head injury
C) stab wound to the chest
D) traumatic amputation of a thumb
3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
A) The clothing is the property of another and must be treated with care.
B) Such care facilitates repair and salvage of the clothing.
C) The clothing of a trauma victim is potential evidence with legal implications.
D) Such care decreases trauma to the family members receiving the clothing.
4. Which of the following terms refers to soft-tissue injury caused by blunt force?
A) contusion
B) strain
C) sprain
D) dislocation
5. A client with dumping syndrome should ___________ while a client with GERD should ___________.
A) sit up 1 hour after meals; lie flat 30 minutes after meals
B) lie down 1 hour after eating; sit up at least 30 minutes after eating
C) sit up after meals; sit up after meals
D) lie down after meals; lie down after meals
1. Right Answer: C
Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This clientsBMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a clients BMI, activity status, and energy requirements. Physiological Adaptation
2. Right Answer: C
Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. Physiological Adaptation
3. Right Answer: C
Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident. Physiological Adaptation
4. Right Answer: A
Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress.A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Physiological Adaptation
5. Right Answer: B
Explanation: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus. Basic Care and Comfort
Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This clientsBMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a clients BMI, activity status, and energy requirements. Physiological Adaptation
2. Right Answer: C
Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. Physiological Adaptation
3. Right Answer: C
Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident. Physiological Adaptation
4. Right Answer: A
Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress.A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Physiological Adaptation
5. Right Answer: B
Explanation: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus. Basic Care and Comfort
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