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Test Prep NCLEX-PN Exam
National Council Licensure Examination(NCLEX-PN) (Page 21 )

Updated On: 30-Jan-2026
Page 21 of 204
PDF with 1015 Questions

Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

  1. refusal to walk
  2. not pulling to a standing position
  3. negative Trendelenburg sign
  4. negative Ortolani sign

Answer(s): B

Explanation:

The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age.
Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.



A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes.

Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

  1. administering immune globulin intravenously
  2. assessing the extremities for edema, redness and desquamation every 8 hours
  3. explaining progression of the disease to the client and his or her family
  4. assessing heart sounds and rhythm

Answer(s): C

Explanation:

Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve.
Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.



Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

  1. immobility
  2. altered growth and development
  3. hemarthrosis
  4. altered family processes

Answer(s): D

Explanation:

Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia.
Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis.
The longterm effects of hemophilia can include problems related to immobility.
Altered growth and development could not have developed in a newly diagnosed client.
Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.



Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except ______________.

  1. terminating the pregnancy
  2. preparing for the birth of a child with special needs
  3. accessing support services before the birth
  4. completing the grieving process before the birth

Answer(s): D

Explanation:

If findings are ominous, the grieving process will not be completed before birth.
If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies.
Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero.



A client who is experiencing infertility says to the nurse, “I feel I will be incomplete as a man/woman if I cannot have a child.”

Which of the following nursing diagnoses is likely to be appropriate for this client?

  1. Risk for Self Harm
  2. Body Image Disturbance
  3. Ineffective Role Performance
  4. Powerlessness

Answer(s): B

Explanation:

Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child.

Nothing in the statement indicates that the client is at risk for harming herself.
Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent’s role.
Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.



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