Practice NCLEX question

[guest769224]

Here is a practice NCLEX question for all the nursing students taking a pediatrics class out there. Let's see how everyone does.

A nurse is caring for a hospitalized 2-year-old child who throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to help alleviate the child's stress?

A. Set of building blocks

B. Toy hammer and pounding board

C. Picture book about hospitals

D. Stuffed animal

Good luck!

[NuGuyNurse2b]

I just spent an entire weekend with a little kid who was missing his parents, and he wouldn't even look at a novel stuffed animal, didn't want to be cuddled or read to, likes to bang things together, and loves blocks. The Duplos (toddler-sized Legos) we had were an instant attention-getter and tantrum-blocker. Great distraction.

Also, there is recent research that shows "hitting" toys like banging-hammer-peg-benches and punching bags actually increase a child's tendency towards aggression, reinforcing violent acts by offering opportunities to practice them and get approbation for doing them; they do not "release tension." Little guys can release tension in the blink of an eye with the right distraction. Saying yes to " 'nack?" is also good.

Thus endeth the grandma's lesson for today.

hmmm he could form a hammer with those Duplos ...

[JustBeachyNurse, LPN]

hmmm he could form a hammer with those Duplos ...

Different cognitive process than simply "acting out aggression" the time taken to create a hammer uses different neural pathways and may actually redirect thoughts of violence and destruction to creativity and fortitude to complete the desired design.

[nurseprnRN, BSN, RN]

I have 2 questions if anyone wants to try more.

1. The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

1. Assess respiratory status.

2. Draw blood for laboratory studies.

3. Insert a Foley catheter.

4. Weigh the client.

2. You are the nurse of a healthcare team that consists of one licensed practical/vocational nurse, one nursing assistant, a nurse student, and yourself. To whom is it appropriate to assign complete care for?

1. Yourself

2. The nursing student

3. The licensed vocational nurse

4. The nursing assistant

Resp status is always first, and can (and should) be assessed in multiple ways at this time. Observe for SOB with exertion, ask about it ("Have you noticed ...?"), and listen to the chest especially dependent areas.

Weight is a close second, because you know diuresis will be part of the medical plan of care soon to begin, and you want that baseline for monitoring it and to illustrate for patient teaching.

This question on delegation is asking whether you know scopes of practice. The only possible answer is 1, yourself. It's not the student, because the level of the student is not specified and student scope may be limited by the school-facility agreement or other factor. LPN scope does not include assessment and plan of care development by law and may not include certain procedures, meds, or other tasks. Obviously the NA is out.

[Graduatenurse14]

I said B or D. Glad that I was half-right. After looking at the other questions, I don't know how I passed the NCLEX with 75 a mere year ago!! I swear it's more luck!! As for the other two, I will bold my answers!

1. The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

1. Assess respiratory status. ( # 1 pick- ABC and don't need an order.)

2. Draw blood for laboratory studies.

3. Insert a Foley catheter.

4. Weigh the client. (Maybe this one. People with CHF should weigh themselves daily and we need an admission weight for baseline anyway.)

2. You are the nurse of a healthcare team that consists of one licensed practical/vocational nurse, one nursing assistant, a nurse student, and yourself. To whom is it appropriate to assign complete care for?

1. Yourself

2. The nursing student

3. The licensed vocational nurse

4. The nursing assistant (In my world "complete" is more about ADLs not the RN care at all. I forget what "complete" meant in the NCLEX world)

[Larry2016]

I narrowed down the answer to B or D and had good rationales for each. I was suspicious about B because, eve though it may be more therapeutic, the child can injure itself even more with the hammer. Then you have an irate parent for giving their child a toy that could do them harm. The stuffed animal could either soothe the child or they could try to rip it apart.

[NuGuyNurse2b]

4. The nursing assistant (In my world "complete" is more about ADLs not the RN care at all. I forget what "complete" meant in the NCLEX world)

that's how I read it too. so when grntea said 1 I was like WHAT??!!

[Tenebrae, BSN, RN]

A, C, D are correct answers, but they are not the most correct answers.

Seriously I'm glad to be done with this. I think if my almost three years out of nursing has taught me anything, its life is never as black and white as it is in state final/nclex questions

[nurseprnRN, BSN, RN]

that's how I read it too. so when grntea said 1 I was like WHAT??!!

"Total care" doesn't mean just totally dependent for physical care, although many CNAs and students take it that way. As I said, this question is there to evaluate your knowledge of scopes of practice. Total care includes assessment, meds, treatments, everything a patient needs. Remember that. Delegation is not some esoteric concept. Failure to delegate properly is involved in many of the legal cases I review. It is a big deal.

[NuGuyNurse2b]

I swear there are moments I learn more here than I did in school.

[WellThatsOod]

"Total care" doesn't mean just totally dependent for physical care, although many CNAs and students take it that way. As I said, this question is there to evaluate your knowledge of scopes of practice. Total care includes assessment, meds, treatments, everything a patient needs. Remember that. Delegation is not some esoteric concept. Failure to delegate properly is involved in many of the legal cases I review. It is a big deal.

This is what I thought when I read "total care."

[traumaRUs, MSN, APRN]

Please do not post questions and answers from ANY copyrighted material - thanks much.

[DLau]

Hey ICUman, i just came across this question on a NCLEX practice test i got from my college. I'm a recent RN grad, studying for boards. I got this question wrong, which was especially frustrating because there was no rationale provided with the answer key. Did you get it from a specific NCLEX prep book or app maybe? If so, if you could let me know the source, i'd appreciate it. Thanks! -DM