Prepping for NCLEX with prep-u Qs

The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them?

Dehydration is expected during the dying process

A depressed client on a psychiatric unit asks the nurse to call the hospital lawyer to discuss writing out a will. What is the nurse's priority intervention?

Discuss thoughts and explore intent for suicide with the client. Exploration of thoughts and intent are a priority based on lethality of plan for suicide. The nurse would discuss the intent with the client prior to calling the physician.

Which intervention should the nurse suggest to a parent to relieve itching in a child with chicken pox?

Q8

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the mother and partner to do?

Relate to each twin individually to enhance the attachment process.

pancytopenia

deficiency of all types of blood cells

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner?

humidify air being delivered

Arrangements are made for a member of the colostomy support group to meet with a client before bowel surgery. What is accomplished by having a representative from the group meet the client preoperatively?

providing the client with support and realistic information on the colostomy Preoperative visits and talks with others who have made successful adjustments to colostomies are helpful and tend to make the client less fearful of the operation and its consequences

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?

"Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack."

The client exhibits a flat affect, psychomotor deficits, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate?

"I'll sit here with you for 15 minutes."

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate?

"The diagnosis won't be based on the findings of a single test but by combining all data found."

A child has been prescribed a 3-day treatment of gentamicin sulfate. Which manifestation would indicate that the child is developing toxicity?

Gentamicin sulfate is an antibiotic that can cause ototoxicity and nephrotoxicity. Therefore, a decrease in renal output would be concerning.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

LIe down or sit for 5-10 minutes after taking drug

A terminally ill client has a health care directive (advanced directive) that indicates "do not intubate" in the event of respiratory failure. The client is now unresponsive and the family requests that "everything be done" to support the client's breathing. What action(s) should the nurse take in this situation? Select all that apply.

Request the health care provider speak with the family related to prognosis and realistic expectations should intubation be performed for the client. Interview the family members about their wishes for spiritual and psychological supports related to the anticipated death and dying process.

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:

may be experiencing increased energy and is at increased risk for suicide. As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan

The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement?

"It is important that you visit even for 1 hour." Stressing the importance of the parents' visiting when they can helps to alleviate the guilt they feel. It allows the parents to feel that they are doing what they can

A seriously ill client's spouse tells the nurse, "I would like to be physically closer with my spouse, but I am afraid of causing pain if I touch my spouse." How should the nurse respond?

"It is normal to fear causing pain. What kind of contact did you want to have with your spouse?"

A new nurse is leading a family education group for those who have relatives with paranoid schizophrenia. Which statement by the new nurse indicates the need for further teaching about symptom management?

"The more we push the clients to spend time with friends, the more their voices decrease."

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?

"You're very concerned when you think about how this will change your life."

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the mosttherapeutic response by the nurse?

You are concerned the client is receiving too much narcotic medication?

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. Which of these best describes a subculture?

a unique cultural group that exists within the larger culture

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?

Contact the surgeon to answer the client's question.

A client states, "I feel so sad. I don't think I can go on anymore." Which is the most therapeutic response the nurse can offer the client?

"You feel like you can't go on anymore?"

An elderly Jewish client received a lunch tray that consists of a cheeseburger, French fries, and an apple. The client tells the nurse to remove the tray. What is the nurse's understanding of why the client wants the tray removed?

Clients of Jewish faith do not allow the mixture of dairy and meat

Barlow vs Ortolani

Push down on adducted leg (barlow) vs Push on greater trochanter with leg abducted to see if it dislocates (ortolani)

When conducting a psychoeducational group session on relapse prevention for clients dually diagnosed with chronic schizophrenia and alcohol abuse, the nurse should use which approach?

concrete concepts and simplified material Clients with dual diagnosis experience difficulties in concentration and memory due to the effects of schizophrenia and the use of alcohol. Groups should be structured with simplified material and concrete concepts. Handouts and simple homework assignments may be helpful for the clients to review and apply concepts learned in the group session.

A child who is of preschool age is diagnosed as having severe autism. The most effective therapy involves which intervention?

one-on-one play therapy The preschool-aged child with severe autism will benefit from one-on-one play therapy. The therapist can develop a rapport with this child with nonverbal play.

Types of Grief

uncomplicated, anticipatory, complicated, disenfranchised, dysfunctional, Dysfunctional grief--> is intense grief that does not result in reconciliation of feelings, such as this client is experiencing. Anticipatory grieving--> is grief before the actual loss occurs. Uncomplicated grief--> is a grief reaction that normally follows a significant loss and proceeds normally. Disenfranchised grief--> is grief that is not openly acknowledged, socially sanctioned, or publicly shared complicated grief--> a chronic, heightened state of mourning. Its symptoms can include: Extreme focus on the loss and reminders of the loved one. Intense longing or pining for the deceased. Problems accepting the death