NCLEX-RN : Patient-Specific Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #75 : Procedures And Care

By what age should an infant be able to pull itself up to standing?

Possible Answers:

9 months

12 months

6 months

18 months

Correct answer:

9 months

Explanation:

An infant should have the ability to pull itself up to standing by the age of 9 months. If standing is not seen after 12 months the child should be evaluated for any type of physical developmental disabilities or delays.

Example Question #26 : Care

At what age can an infant begin eating solid foods?

Possible Answers:

4 months

3 months

9 months

6 months

Correct answer:

6 months

Explanation:

Solid foods should not be introduced into an infant's diet before 6 months of age. Earlier introduction may trigger specific food allergies, as well as reducing breastmilk production in a breastfeeding mother.

Example Question #1 : Pediatric Care And Development

An audible click when the examiner slips the femoral head forward is considered positive for what sign?

Possible Answers:

Brudzinski sign

Ortolani sign

Scarf sign

Babinski sign

Correct answer:

Ortolani sign

Explanation:

An audible click when the examiner slips the femoral head forward is considered a positive Ortolani sign. This finding suggests congenital hip dysplasia. Babinski sign is the presence of the Babinski reflex, which is normal in infants. Scarf sign is used to assess developmental age and muscle tone in neonates. Brudzinski sign is not related to the musculoskeletal system but is part of a physical examination in cases of suspected meningitis.

Example Question #1 : Pediatric Care And Development

At what age does the posterior fontanelle close?

Possible Answers:

4 weeks

8 weeks

16 weeks

12 weeks

Correct answer:

8 weeks

Explanation:

The posterior fontanelle, which is the cartilaginous  gap at the junction of the lambdoid suture and the sagittal suture, closes at eight weeks of age.

Example Question #27 : Care

By what age should an infant have doubled it's birth weight?

Possible Answers:

3 months

6 months

12 months

9 months

Correct answer:

6 months

Explanation:

An infant should have doubled it's birth weight by the age of six months, and tripled it's birth weight by the age of 12 months. Children who fail to reach these markers may be underweight due to a variety of factors such as underfeeding, metabolic disorder, or failure to thrive.

Example Question #5 : Pediatric Care And Development

Which of the following is not part of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for autism spectrum disorder (ASD)?

Possible Answers:

Highly restricted, fixated interests that are abnormal in intensity or focus

Stereotyped or repetitive motor movements, use of objects, or speech

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment

Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

Correct answer:

Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

Explanation:

All of the behaviors listed are part of the diagnostic criteria for autism spectrum disorder except for disruptive hyperactivity-impulsivity present for a period of greater than six months, which is part of the DSM-5's diagnostic criteria for attention deficit hyperactivity disorder (ADHD), not for autism spectrum disorder (ASD). 

Example Question #6 : Pediatric Care And Development

A mother brings her seven year old daughter into the emergency room after she fell while riding her bike. She was not wearing a helmet and she hit her head on the asphalt.

Which of the following is not a sign of late-stage increased intracranial pressure (ICP) in a pediatric patient?

Possible Answers:

Fixed, dilated pupils

Diminished level of consciousness

Bradycardia

Dilated scalp veins

Correct answer:

Dilated scalp veins

Explanation:

Diminished level of consciousness, bradycardia, and fixed and dilated pupils are all signs of later-stage intracranial pressure (ICP). Dilated scalp veins may be present with ICP, but will be seen in the early stages of the condition. 

Example Question #7 : Pediatric Care And Development

A nurse is instructing a parent on proper care for their seven-year-old son who has recently been diagnosed with a seizure disorder. In regards to care during a seizure, the nurse should advise the parent to do all of the following except __________.

Possible Answers:

Stay with the child for the duration of the episode

Place a padded tongue blade in the child's mouth

Note the length of the seizure

Move furniture away

Correct answer:

Place a padded tongue blade in the child's mouth

Explanation:

A parent of a child with a seizure disorder should be instructed to stay with the child through the duration of the seizure, to move any nearby furniture out of the way of the child to prevent trauma, and to note and record the length of the seizure. No object should ever be put into the mouth of a child who is having a seizure.

Example Question #8 : Pediatric Care And Development

Which of the following would increase suspicion of strabismus in a pediatric patient?

Possible Answers:

The child consistently squints or tilts head to see

The child complains of frequent nausea

The child does not respond to loud or sudden noises

Difficulty holding eye contact or responding to social cues

Correct answer:

The child consistently squints or tilts head to see

Explanation:

Strabismus is a misalignment of the eyes that results in one eye becoming dominant over the other. It does not affect hearing or ability to connect to others socially. This condition should not result in nausea.

Example Question #1 : Pediatric Care And Development

The nurse in the primary care clinic meets with a 22-month-old boy and his mother, who is concerned about his sleeping habits. He cannot sleep without a bottle of milk and wakes during the night to ask for more. What should the nurse tell the child’s mother?

Possible Answers:

“It is better for you to leave him with water instead of milk.”

“Let him have one bottle of milk at bedtime, but do not give a second bottle.”

“Put juice in the bottle instead of milk.”

“He can have a bottle of milk before bedtime, and you can give him another bottle when he asks.”

“Do not let him have any bottles in the crib.”

Correct answer:

“It is better for you to leave him with water instead of milk.”

Explanation:

Babies and toddlers should not fall asleep with bottles full of milk or juice with them at bedtime. Plain water would be acceptable for a child to have at bedtime, as it does not have any sugar. The sugar in milk and juice will remain in the child’s mouth during sleep and cause caries, even if the teeth are not fully formed. It is common for babies to lose interest in bottles at night time when water is substituted.

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