NCLEX-NCBSN MANAGEMENT OF CARE
The charge nurse on the evening shift is asked to determine which client is a candidate for discharge following an internal disaster in the hospital at 9:00 pm. Which of these clients should the nurse select as a potential candidate for discharge? A young adult, admitted at the beginning of the shift, with an exacerbation of asthma A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis An adolescent, admitted on the day shift to rule out acute pancreatitis, who reports a history of alcohol abuse An older adult female who is actively dying and has a "do not resuscitate" order
A MIDDLE-AGED ADULT WITH A HISTORY OF TYPE 1 DIABETES AND ONE DAY POST DIABETIC KETOACIDOSIS The client selected to be discharged should be one whose condition is more stable than the others and where there's less of a risk for complications or instability after discharge. Although the client with asthma has a chronic condition, s/he was just admitted and is experiencing an acute exacerbation of the condition. The adolescent is experiencing an acute condition, probably brought on by his/her alcohol abuse. Neither of these clients are stable enough for discharge. It is a humane choice to allow the client who is in the process of dying to stay in the hospital.
The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients? A young adult who was admitted 24 hours ago for treatment following detoxification An elderly person who was admitted three hours ago with a diagnosis of cyclothymia An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder
A MIDDLE-AGED PERSON WHO HAS BEEN ON THE UNIT FOR 72 HOURS WITH A DIAGNOSIS OF PERSISTENT DEPRESSIVE DISORDER These findings suggest depression. The most therapeutic milieu for this client includes double occupancy with someone who has similar issues and/or whose condition is more stable. A secondary consideration is matching roommates' ages as closely as possible, because they potentially would share similar developmental challenges and needs. The most stable client is the one with persistent depressive disorder. Cyclothymia is an illness that's similar to bipolar disorder and disruptive mood dysregulation disorder is characterized by irritability and episodes of extreme, out-of-control behavior.
A nurse is performing a nutritional assessment on a 2 year-old child. Which of these principles should the nurse apply? Increased serum albumin or prealbumin levels indicate malnutrition Total intake varies greatly each day A serving size at this age is about two tablespoons An accurate measurement of intake is not reliable
A serving size at this age is about two tablespoons In children, a general guide to serving sizes is one tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake for any aged child.
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? It is an incident management technique that focuses on employee retention Top administrators are responsible for establishing plans for problem management All employees participate in systematically working toward common goals It is a reactionary approach used to investigate the root cause of a problem
ALL EMPLOYEES PARTICIPATE IN SYSTEMATICALLY WORKING TOWARD COMMON GOALS TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top administrators. It is a proactive, not reactive, approach to solving problems.
Parents bring their special needs child to a community health center one day after an explosion occurred at the child's high school. It is determined that the child may be in a crisis state. Which of these interventions is appropriate to implement at this time? Make the child identify a specific problem Ask the parent to identify the major issue(s) Discuss a variety of alternative approaches with the child Examine a variety of options with the parent
ASK THE PARENT TO IDENTIFY THE MAJOR ISSUE If a client is unable to participate in problem solving because of developmental delays or altered mental status, then crisis intervention should not be attempted with the client. However, the family can be approached with the use of crisis intervention methods. The crisis intervention method includes five steps: identify the problem and then the alternatives, selection of an alternative, implementation, and evaluation of the outcome.
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? Frustration with adults Stubborn behavior Rejection of parents Assertion of control
ASSERTION OF CONTROL Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.
The nurse is assessing the mental status of a client admitted with possible dementia. Which of these options would best assess the functioning of the client's short-term memory? Ask the client to copy an image of two simple, intersecting geometric shapes Ask the client to name the last four presidents Ask the client to calculate simple arithmetic operations Ask the client to recall three words the nurse had previously asked the client to remember
Ask the client to recall three words the nurse had previously asked the client to remember RATIONALE:Short-term memory refers to the temporary storage of information in memory and the management of the information so that it can be used for more complex cognitive tasks, such as learning and reasoning. Tests of cognitive function are used to evaluate cognitive impairment. The Mini-Mental Status Exam, for example, measures orientation to time and place, calculation, language, short-term verbal memory, and immediate recall. To help determine short-term memory functioning, the health care practitioner would ask the client to recall three words that the client had previously been asked to remember.
The nurse is assessing the heart sounds of a client admitted to the telemetry unit with a diagnosis of mitral stenosis.
Auscultation of heart sounds is a key component of the physical assessment. It is important that the nurse is able to identify the area on the chest that corresponds to each of the four valves. The mitral area or apex of the heart is located at the fifth intercostal space, left midclavicular line.
An 80 year-old client has taken a benzodiazepine for insomnia for many years. The client now reports experiencing anxiety and some confusion. What is the most likely reason for this? Decreased liver function Decreased gastrointestinal motility Poor rate of elimination by the kidneys Decrease in lean body mass and increase in body fat
DECREASE IN LEAN BODY MASS AND INCREASE IN BODY FAT Absorption, distribution and elimination of medications are all affected by age-related changes. Since drug distribution is most affected by the change in body fat and lean body mass, this can lead to increased elimination half-life and prolonged effect of lipid soluble drugs such as benzodiazepines. Dosages that may have a therapeutic effect for a 65 year-old can produce significant side effects for older clients.
The nurse is caring for the neonate immediately following a vaginal delivery. Which of the following interventions will promote temperature regulation in the neonate? (Select all that apply.) Dry the neonate off with warm towels Bathe the neonate to remove contaminants from the delivery Place the neonate under a radiant warmer Encourage skin-to-skin contact with the mother Wrap the neonate in blankets
DRY THE NEONATE PLACE THE NEONATE UNDER A RADIANT WARMER ENCOURAGE SKIN TO SKIN CONTACT WRAP THE NEONATE IN BLANKETS After drying off the wet amniotic fluid, placing the neonate under the radiant warmer or placing the neonate skin to skin against the mother will provide a source of heat for the neonate. Wrapping the neonate in blankets will help to reduce heat loss. The neonate should not be bathed until the temperature is stabilized.
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) Family preferences Client health status Excellent primary care Reconciliation of medications Poor communication among providers
FAMILY PREF CLIENT HEALTH STATUS POOR COMMUNICATION AMONG PROVIDERS Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.
The nurse is offering safety instructions to a parent with a 4 month-old infant and a 4 year-old child. Which statement by the parent indicates a correct understanding of the appropriate precautions to take with the children? "I strap the infant car seat on the front seat to face backwards." "I place my infant in the middle of the living room floor on a blanket to play with my 4 year-old while I make supper in the kitchen." "I have the 4 year-old hold and help feed the 4 month-old a bottle with me." "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the 4 year-old naps on the sofa."
I HAVE THE 4 YR OLD HOLD AND HELP FEED THE 4 MONTH-OLD A BOTTLE WITH ME The infant seat should be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their back when they go to sleep or are lying in a crib. A four year-old could assist with the care of an infant such as feeding with proper direct supervision.
The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the mobility training program. What action is the nurse's priority? Contact the family to discuss preoperative mobility problems Discuss the problem with the client's surgeon Instruct physical therapy to increase treatments to four times a day Inform the case manager of the variance in the critical pathway
INFORM THE CASE MANAGER OF THE VARIANCE IN THE CRITICAL PATHWAY Variances in the critical pathway need to be reported to the case manager. Certain goals need to be met to move the client forward in recovery and transfer to an appropriate venue for continued rehabilitation. The RN cannot order physical therapy treatment. Previous mobility problems are not priority post-operatively. The surgeon needs to be informed about the client's lack of progress, but this is not the priority.
A nurse prepares for a Denver Screening II of a 3 year-old child in the clinic when the mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver Screening II? "It assesses a child's development." "It evaluates psychological responses." "It helps to determine problems." "It measures a child's intelligence."
IT ASSESSESS A CHILD'S DEVELOPMENT The Denver Developmental Test II is a screening test to assess children from birth through six years of age in the personal/social, fine motor adaptive, language and gross motor development. During this test a child experiences the fun of play. This screening test determines the highest level of functioning in these areas at the time of the examination.
The registered nurse (RN) is making a presentation about Lyme disease to a group of volunteers who host hiking tours through grassy areas. Which statement made by one of the volunteers indicates more teaching is needed? "Lyme disease can spread to my brain if I don't seek treatment." "I should wear light-colored clothing and long pants when hiking." "Lyme disease is caused by a virus because the symptoms are similar to the flu."
LYME DX IS CAUSED BY A VIRUS BECAUSE THE SYMPTOMS ARE SIMILAR TO THE FLU Lyme disease is caused by bacteria called Borrelia burgdorferi. It is transmitted by ticks (the ticks pass it on from infected mice or deer.) Because the ticks are so small, it is easier to see them on light-colored clothing; long pants and long-sleeved shirts help protect hikers. Symptoms of Lyme disease are similar to influenza and there may be a "bull's eye" rash at the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart and joints of the body.
The nurse is assessing a pregnant client in her third trimester. The client is informed that the ultrasound suggests the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what factor? Exposure to teratogens Sexually transmitted infection Chromosomal abnormalities Maternal hypertension
MATERNAL HYPERTENSION Pregnancy-induced hypertension is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients. The other three conditions are associated with the first trimester time period.
A Native-American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The charge nurse tells a colleague, "I wonder if he has any idea how ridiculous he looks - he's a grown man!" This statement is an example of which non-therapeutic approach? Ethnocentrism Discrimination Prejudice Stereotyping
PREJUDICE In this question, the nurse is reacting to the chief's behavior, which is an example of prejudice. Prejudice reflects the overall attitude and emotional response (both positive and negative, conscious and non-conscious) to a group. Discrimination refers to differences in actions towards different groups on the basis of prejudice. Stereotypes are cognitions or beliefs used to categorize others and systemize information in order to better predict behavior and react. Stereotypes can be used to develop prejudices toward others and to discriminate. Ethnocentrism is the practice of making judgments about other cultures based on the values and beliefs of one's own culture (especially related to language, customs and religion.)
The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? Teach the initial ostomy care to a client and family members Care for a recent complicated double barrel colostomy Provide stoma care for a client with a well-functioning ostomy Assess the function of a newly created ileostomy
PROVIDE STOMA CARE FOR A CLIENT WITH A WELL-FXN OSTOMY The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN.
The nurse performs a heal stick for a blood glucose check on a 1 hour-old, full-term newborn who weighed 9 pounds (4.1 kg) at birth. The serum glucose reading is 45 mg/dL (2.5 mmol/L). What action is needed by the nurse? Give oral glucose water Repeat the test in two hours Notify the pediatrician Check the pulse oximetry reading
REPEAT THE TEST IN TWO HOURS A serum glucose of 45 mg/dL (2.5 mmol/L) is considered normal (normal range for the neonate is about 40-90 mg/mL or 2.2-5.0 mmol/L). Neonatal hypoglycemia is defined as a blood glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter. Risk for hypoglycemia includes newborns who weigh more than 4 kg or less than 2 kg at birth, are large for gestational age; also gestational age less than 37 weeks and newborns suspected of sepsis are also high risk and should be screened for hypoglycemia in the first hour of life. Due to the weight of the newborn, repeat blood glucose testing is indicated.
A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? Immediately call security for this breach in client confidentiality Request to see identification and an explanation as to why the woman is viewing client charts Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care Report to the nurse manager about the witnessed suspicious activity
REQUEST TO SEE ID AND AN EXPLANATION AS TO WHY THE WOMAN IS VIEWING CLIENT CHARTS Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation.
Behaviors of alcohol and drug abuse have outcomes of impaired judgment and increased risk-taking behavior. What nursing diagnosis best applies to this data? Altered thought process Risk for knowledge deficit Disturbance in self-esteem Risk for injury
RISK FOR INJURY Accidents increase as a result of intoxication of substances. Studies indicate alcohol is a factor in more than 50% of motor vehicle fatalities, in 53% of all deaths from accidental falls, in 64% of fatal fires, and in more than 80% of suicides.
During a home visit, the nurse observes the mother of a school-aged child in a long leg synthetic cast using a cloth-covered wooden spoon handle to relieve itching inside the cast. Which response by the nurse is most appropriate? Instruct them to blow hot air from a hand-held hair dryer into the cast Remind the mother and child that itching is normal Suggest placing an ice pack (protected by plastic) over the area that is itching No response is needed because the mother's behavior is appropriate
Suggest placing an ice pack (protected by plastic) over the area that is itching RATIONALE:Because itching is a common and frustrating problem for a person with a cast, it would not be therapeutic to simply remind the mother and child that itching is normal. But using anything to scratch the skin inside the cast is not recommended because this can injure the skin, increasing the risk for infection. Clients may use a hair dryer to help relieve itching, but the temperature must be set to cool or cold. Of the given choices, applying ice (protected by a plastic bag) is the most appropriate. Cool temperatures constrict blood vessels, minimizing itching (just like heat vasodilates and intensifies itching.) Sometimes over-the-counter antihistamines may help relieve itching.
A parent asks the nurse about a Guthrie Bacterial Inhibition test that was ordered for her newborn. Which of the following points should the nurse discuss with the client prior to this test? (Select all that apply.) The urine test can be done after six weeks of age Routine screening of newborn infants is not mandatory in the United States The test will be delayed if the baby's weight is less than 5 pounds This test identifies an inherited disease Positive tests require dietary control for prevention of brain damage Best results occur after the baby has been breast-feeding or drinking formula for two full days
THE URINE TEST CAN BE DONE AFTER 6 WKS OF AGE THE TEST WILL BE DELAYED IF THE BABY'S WEIGHT IS LESS THAN 5 LBS This test identifies an inherited disease Positive tests require dietary control for prevention of brain damage Best results occur after the baby has been breast-feeding or drinking formula for two full days RATIONALE:Screening for PKU is mandated in all 50 states, though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow-up test 7 to 10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of age if a baby did not have the blood test.
The nurse is explaining an illness to a 10 year-old child. What should the nurse keep in mind about the cognitive development of children at this age? Interpretation of events originate from their own perspective They are able to think logically in the organization of facts Children of this age are able to make simple association of ideas Conclusions are based on previous experiences
THEY ARE ABLE TO THINK LOGICALLY IN THE ORGANIZATION OF FACTS Children in the concrete operations stage, according to Piaget, are capable of mature thought when they are allowed to mentally or physically manipulate and organize objects.
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? Tracheostomy of 24 hours with the client showing some respiratory distress Report of unstable angina with continuous telemetry monitoring Dopamine IV drip with vital signs monitored every five minutes Pacemaker insertion on the day shift
The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in critical care should not be assigned to the client with a newly created tracheostomy
A client referred for mammography questions the nurse about the cancer risks from radiation exposure. What is an appropriate response by the nurse? "A chest x-ray gives you more radiation exposure." "Exposure to mammography every two years is not dangerous." "You have nothing to worry about; it is less than tanning in the nude." "The radiation from a mammography is equivalent to one hour of sun exposure."
The radiation from a mammography is equivalent to one hour of sun exposure." A client would have to have several mammograms in a year's time to be at risk for cancer. The radiation exposure from one mammogram session is thought to be equivalent to being out in natural sunlight for one hour. This answer is concise and gives the client a point of reference. To say not to worry is judgmental and nontherapeutic. In the other two options one is not accurate and can cause further concern about radiation exposure and one does not clearly address the client's question.
The school nurse is checking students for pediculosis capitis. Which manifestation observed by the nurse confirms the presence of pediculosis capitis? Oval pattern of occipital hair loss Whitish oval specks sticking to the hair shaft Scratching the head more than usual White flakes on the student's shoulders
WHITISH OVAL SPECKS STICKING TO THE HAIR SHAFT Diagnosis of pediculosis capitis, or head lice, is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years-old and meticulous combing with a special comb for the removal of all nits. Flakes could be as benign as dandruff or dried hair product. While scratching the head could be caused by head lice infestation, it can also be attributed to many different causes. Oval pattern of hair loss can be caused by many different things, including tinea capitis (ringworm) and hair shaft trauma (child pulling out the hair).
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects assertive communication? "Would you please clarify what you have written so I am sure I am reading it correctly?" "Please print in the future so I do not have to spend extra time attempting to read your writing." "I cannot give this medication as it is written. I have no idea of what you mean." "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
WOULD YOU PLEASE CLARIFY WHAT YOU HAVE WRITTEN SO I AM SURE I AM READING IT CORRECTLY Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.
The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in an automobile. What is the nurse's best response to the parents? "Your child must use a car seat until he weighs at least 40 pounds." "The child must be five years of age to use a regular seat belt." "The child can use a regular seat belt when he can sit still." "Your child must reach a height of 50 inches to sit in a seat belt.
YOUR CHILD MUST USE A CAR SEAT UNTIL HE WEIGHS AT LEAST 40 POUNDS The guidelines for car seats depend on the child's weight, height, age and car type. Children should use car seats until they weigh 40 pounds (according to the U.S. National Highway Traffic Safety Administration).
The nurse is performing the following actions immediately following the delivery of a healthy, normal newborn. Indicate the correct sequence of actions by dragging and dropping the options below into the correct orderAssessing
the airway and respirations is the first action. Next, if indicated, the baby would be suctioned. Then the heart rate is assessed. After these initial assessments, the identification bands are placed on both mother and baby. IM administration of vitamin K is recommended for the newborn but this can be done after the initial assessments and proper identification.
