Below you will find a comprehensive set of multiple-choice questions (MCQs) formatted with
options A, B, C, and D, along with their correct answers and thorough “Expert-Verified” explanations.
Each question is labeled with a potential “Question Type” to reflect either a standard format or
indicate how it might appear within Next Generation NCLEX (NGN) or a case-based scenario. This
layout offers advanced personalization by weaving in critical reasoning rationales for nursing practice,
dietary advice, psychosocial considerations, cultural competence, and therapeutic communication
techniques. Use these items as a resource for study, review, or discussion.
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1) (NGN-Style: Single Best Response)
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing
intervention is appropriate for this child?
A. Make certain the child is maintained in correct body alignment.
B. Be sure the traction weights touch the end of the bed.
C. Adjust the head and foot of the bed for the child's comfort.
D. Release the traction for 15–20 minutes every 6 hours PRN.
Answer: A. Make certain the child is maintained in correct body alignment.
Expert-Verified Explanation:
• Proper body alignment is a priority in any skeletal traction to ensure effective traction pull and
prevent complications such as nerve damage, skin breakdown, or improper bone healing.
• Weights should hang freely (never resting on the floor or bed), and frequent assessment of the ropes
and pulleys is critical.
• Releasing traction without an order can disrupt the healing process. Therefore, correct alignment is
the single most important intervention for orthopedic traction.
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,2) (Standard Multiple Choice)
The nurse is assessing a healthy child at the 2-year checkup. Which of the following should the nurse
report immediately to the health care provider?
A. Height and weight percentiles vary widely.
B. Growth pattern appears to have slowed.
C. Recumbent and standing height are different.
D. Short-term weight changes are uneven.
Answer: A. Height and weight percentiles vary widely.
Expert-Verified Explanation:
• When height and weight differ significantly in percentiles (e.g., height at the 10th percentile but
weight at the 90th), it can point to nutritional imbalances, endocrine issues, or other health concerns.
• Minor fluctuations can be normal, but a wide discrepancy in growth parameters usually warrants
medical evaluation to rule out underlying conditions.
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3) (NGN-Style: Single Best Response)
The parents of a 2-year-old child report that he has been holding his breath whenever he has temper
tantrums. What is the best action by the nurse?
A. Teach the parents how to perform cardiopulmonary resuscitation.
B. Recommend that the parents give in when he holds his breath to prevent anoxia.
C. Advise the parents to ignore breath holding because breathing will begin as a reflex.
D. Instruct the parents on how to reason with the child about possible harmful effects.
Answer: C. Advise the parents to ignore breath holding because breathing will begin as a reflex.
,Expert-Verified Explanation:
• Breath-holding spells are common in toddlers during intense frustration or anger. Most children
will spontaneously start breathing again due to automatic brainstem reflexes.
• Excessive attention or “giving in” can reinforce the negative behavior, so a calm, consistent response
is best.
• While training in CPR can be helpful for any parent, the priority is reassuring them that these spells
are self-limiting.
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4) (Case Study Format: Acute Chest Pain)
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is
acute angina?
A. "My pain is deep in my chest behind my sternum."
B. "When I sit up, the pain gets worse."
C. "As I take a deep breath, the pain gets worse."
D. "The pain is right here in my stomach area."
Answer: A. "My pain is deep in my chest behind my sternum."
Expert-Verified Explanation:
• Angina pectoris often presents as a substernal, pressure-like discomfort that may radiate.
• Pain that changes with position (example: sitting up) or respiration is more indicative of pericarditis
or pleuritic pain, respectively.
• Epigastric (stomach area) pain may suggest GI origin rather than cardiac.
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, 5) (NGN-Style: Single Best Response)
The nurse is assessing the mental status of a client admitted with possible organic brain disorder.
Which of these questions will best assess the function of the client's recent memory?
A. "Name the year. What season is this?"
B. "Subtract 7 from 100 and then subtract 7 from that. Continue subtracting 7..."
C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball,
pen."
D. "What is this on my wrist? Then ask, 'What is the purpose of it?'"
Answer: C. "I am going to say the names of three things and I want you to repeat them after me: blue,
ball, pen."
Expert-Verified Explanation:
• Asking the client to recall a short list after a few minutes is a standard test for short-term (recent)
memory.
• Orientation questions (e.g., asking the year, or current season) primarily test orientation, and
subtracting from 100 tests concentration and attention.
• Identifying objects (a watch and its function) tests higher-level cognition or expressive language, not
recent memory.
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6) (Standard Multiple Choice)
In planning care for a 6-month-old infant, what must the nurse provide to assist in the development
of trust?
A. Food
B. Warmth
C. Security
options A, B, C, and D, along with their correct answers and thorough “Expert-Verified” explanations.
Each question is labeled with a potential “Question Type” to reflect either a standard format or
indicate how it might appear within Next Generation NCLEX (NGN) or a case-based scenario. This
layout offers advanced personalization by weaving in critical reasoning rationales for nursing practice,
dietary advice, psychosocial considerations, cultural competence, and therapeutic communication
techniques. Use these items as a resource for study, review, or discussion.
──────────────────────────────────────────
──────────────
1) (NGN-Style: Single Best Response)
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing
intervention is appropriate for this child?
A. Make certain the child is maintained in correct body alignment.
B. Be sure the traction weights touch the end of the bed.
C. Adjust the head and foot of the bed for the child's comfort.
D. Release the traction for 15–20 minutes every 6 hours PRN.
Answer: A. Make certain the child is maintained in correct body alignment.
Expert-Verified Explanation:
• Proper body alignment is a priority in any skeletal traction to ensure effective traction pull and
prevent complications such as nerve damage, skin breakdown, or improper bone healing.
• Weights should hang freely (never resting on the floor or bed), and frequent assessment of the ropes
and pulleys is critical.
• Releasing traction without an order can disrupt the healing process. Therefore, correct alignment is
the single most important intervention for orthopedic traction.
──────────────────────────────────────────
──────────────
,2) (Standard Multiple Choice)
The nurse is assessing a healthy child at the 2-year checkup. Which of the following should the nurse
report immediately to the health care provider?
A. Height and weight percentiles vary widely.
B. Growth pattern appears to have slowed.
C. Recumbent and standing height are different.
D. Short-term weight changes are uneven.
Answer: A. Height and weight percentiles vary widely.
Expert-Verified Explanation:
• When height and weight differ significantly in percentiles (e.g., height at the 10th percentile but
weight at the 90th), it can point to nutritional imbalances, endocrine issues, or other health concerns.
• Minor fluctuations can be normal, but a wide discrepancy in growth parameters usually warrants
medical evaluation to rule out underlying conditions.
──────────────────────────────────────────
──────────────
3) (NGN-Style: Single Best Response)
The parents of a 2-year-old child report that he has been holding his breath whenever he has temper
tantrums. What is the best action by the nurse?
A. Teach the parents how to perform cardiopulmonary resuscitation.
B. Recommend that the parents give in when he holds his breath to prevent anoxia.
C. Advise the parents to ignore breath holding because breathing will begin as a reflex.
D. Instruct the parents on how to reason with the child about possible harmful effects.
Answer: C. Advise the parents to ignore breath holding because breathing will begin as a reflex.
,Expert-Verified Explanation:
• Breath-holding spells are common in toddlers during intense frustration or anger. Most children
will spontaneously start breathing again due to automatic brainstem reflexes.
• Excessive attention or “giving in” can reinforce the negative behavior, so a calm, consistent response
is best.
• While training in CPR can be helpful for any parent, the priority is reassuring them that these spells
are self-limiting.
──────────────────────────────────────────
──────────────
4) (Case Study Format: Acute Chest Pain)
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is
acute angina?
A. "My pain is deep in my chest behind my sternum."
B. "When I sit up, the pain gets worse."
C. "As I take a deep breath, the pain gets worse."
D. "The pain is right here in my stomach area."
Answer: A. "My pain is deep in my chest behind my sternum."
Expert-Verified Explanation:
• Angina pectoris often presents as a substernal, pressure-like discomfort that may radiate.
• Pain that changes with position (example: sitting up) or respiration is more indicative of pericarditis
or pleuritic pain, respectively.
• Epigastric (stomach area) pain may suggest GI origin rather than cardiac.
──────────────────────────────────────────
──────────────
, 5) (NGN-Style: Single Best Response)
The nurse is assessing the mental status of a client admitted with possible organic brain disorder.
Which of these questions will best assess the function of the client's recent memory?
A. "Name the year. What season is this?"
B. "Subtract 7 from 100 and then subtract 7 from that. Continue subtracting 7..."
C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball,
pen."
D. "What is this on my wrist? Then ask, 'What is the purpose of it?'"
Answer: C. "I am going to say the names of three things and I want you to repeat them after me: blue,
ball, pen."
Expert-Verified Explanation:
• Asking the client to recall a short list after a few minutes is a standard test for short-term (recent)
memory.
• Orientation questions (e.g., asking the year, or current season) primarily test orientation, and
subtracting from 100 tests concentration and attention.
• Identifying objects (a watch and its function) tests higher-level cognition or expressive language, not
recent memory.
──────────────────────────────────────────
──────────────
6) (Standard Multiple Choice)
In planning care for a 6-month-old infant, what must the nurse provide to assist in the development
of trust?
A. Food
B. Warmth
C. Security
