NCLEX NCLEX-RN Exam (page: 44)
NCLEX National Council Licensure Examination - -RN
Updated on: 17-Feb-2026

Viewing Page 44 of 345

The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

  1. Immediate treatment of mild PIH includes the administration of a variety of medications
  2. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
  3. Self-discipline is required to control caloric intake throughout the pregnancy
  4. The client may not recognize the early symptoms of PIH

Answer(s): D

Explanation:

(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.



A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

  1. Tetany
  2. Dysrhythmias
  3. Numbness of extremities
  4. Headache

Answer(s): B

Explanation:

(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.



A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

  1. Tetany
  2. Dysrhythmias
  3. Numbness of extremities
  4. Headache

Answer(s): B

Explanation:

(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.



The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

  1. Place a tongue blade in the child's mouth.
  2. Restrain the child so he will not injure himself.
  3. Go to the nurses station and call the physician.
  4. Move furniture out of the way and place a blanket under his head.

Answer(s): D

Explanation:

(A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.



The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

  1. Place a tongue blade in the child's mouth.
  2. Restrain the child so he will not injure himself.
  3. Go to the nurses station and call the physician.
  4. Move furniture out of the way and place a blanket under his head.

Answer(s): D

Explanation:

(A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.



Viewing Page 44 of 345



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