Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 56

1. A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

A) Bulging fontanelles
B) Seizure
C) Headache
D) Ataxia

2. What is the appropriate nursing action for a child with increased intracranial pressure?

A) Head of bed elevated 45 degrees with child - s head maintained in a neutral position
B) Child lying flat
C) Head turned to side
D) Frequent visitation for stimulation

3. A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

A) Head of bed elevated 30 degrees on nonoperative side
B) Head of bed elevated 30 degrees on operative side
C) Bed flat on operative side
D) Bed flat on nonoperative side

4. A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?

A) Bonding
B) Maintain normal blood sugar
C) Maintain normal nutrition
D) Monitor intake and output

5. A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

A) pH 7.39
B) White blood cell (WBC) count 10,000 WBCs/mm3
C) Hematocrit 60%
D) Bleeding time of 4 minutes

1. Right Answer: C
Explanation: (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.

2. Right Answer: A
Explanation: (A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.

3. Right Answer: D
Explanation: (A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.

4. Right Answer: B
Explanation: (A) Bonding is necessary but would not be the priority with this newborn in the nursery. (B) The infant will be at risk for hypoglycemia because of excess insulin production. (C) Normal nutrition is a goal for all newborns. (D) Monitoring intake and output is necessary but is not the most critical nursing goal.

5. Right Answer: C
Explanation: (A) Normal pH of arterial blood gases for an infant is 7.357.45. (B) Normal white blood cell count in an infant is 6,00017,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 27 minutes.

80% DISCOUNT: NCLEX-RN PRACTICE EXAMS