Nurs 4 - Nursing Process: Implementation NCLEX RN EAQ's

The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1 "It must be frustrating to deal with your child's behavior." 2 "Have you considered any alternatives to using medication?" 3 "Perhaps you're looking for an easy solution to the problem." 4 "Let me teach you about the side effects of medications used for ADHD."

1 - "It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.

A 16-year-old girl at 28-weeks' gestation arrives at the prenatal clinic with her mother for a routine sonogram. Before the procedure, the girl asks that the nurse not reveal the fetus's sex if it should become apparent. Afterward, the mother asks the nurse the sex of the fetus. In light of the mother-daughter relationship, what is the best response by the nurse at this time? 1 "That information is not available at this time." 2 "I'm not allowed to divulge confidential information." 3 "Your daughter asked me not to give that information to anyone." 4 "The sex of the baby isn't the most important information at this time."

1 - "That information is not available at this time." Stating that the information is not available at this time supports the client's right to confidentiality without antagonizing the client's mother. Because the expectant mother has requested that the sex of the fetus not be revealed, she has legally and ethically made this information unavailable. Although stating that the nurse is not allowed to divulge that information or that the client has asked it not be given protect the client's right to confidentiality, these responses could disrupt the relationship between the client and her mother. Stating that the sex of the baby isn't the most important information at this time is a judgmental, nontherapeutic statement.

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1 A 59-year-old who had a knee replacement 2 A 60-year-old who has bacterial pneumonia 3 A 68-year-old who had emergency dental surgery 4 A 76-year-old who has a history of thrombocytopenia

1 - A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.

The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? Select all that apply. 1 Assess the wife for caregiver burden. 2 Arrange hospice care for the husband. 3 Make healthcare decisions for the couple 4 Assess the husband for signs of physical abuse. 5 Identify social support within the community.

1 - Assess the wife for caregiver burden. 4 - Assess the husband for signs of physical abuse. 5 - Identify social support within the community. An older caregiver should be assessed for caregiver burden. Anxiety, depression, relationship tension, or health changes are indicators of caregiver burden. The nurse should assess the client for any unexplained bruises or skin trauma; these are signs of physical abuse. These findings must be reported to the state protective agencies. The nurse should also help the couple identify social support within the community. Terminally ill clients who need pain management require hospice care. The nurse need not arrange hospice care for a client with dementia. The nurse should not make healthcare decisions for the client. The client and spouse should be consulted in all healthcare decisions.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN) via an infusion pump. What is most important for the nurse to do when administering TPN? 1 Change the TPN solution bag every 24 hours, even if there is solution left in the bag. 2 Monitor the client's blood glucose level every 2 hours at the bedside with a glucometer. 3 Instruct the client to breathe shallowly when changing the TPN tubing using sterile techniques. 4 Speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate.

1 - Change the TPN solution bag every 24 hours, even if there is solution left in the bag. TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth in the solution; they should be changed daily or sooner if they appear cloudy. Monitoring the blood glucose level every 2 hours is too frequent in ordinary circumstances; the client's blood glucose level should be monitored every 4 to 6 hours to identify the presence of hyperglycemia, a metabolic complication of TPN. The client should not breathe while the TPN catheter is changed because it may result in an air embolus; the Valsalva maneuver should be performed by the client for the few seconds it takes to switch the tubing. An excess amount of glucose will be infused if the rate of the TPN is increased, and the endogenous insulin will be inadequate to meet this demand, resulting in hyperglycemia.

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. 1 Refrain from smoking around the infant. 2 Refrain from co-sleeping or bed-sharing. 3 Position the infant on the side while sleeping. 4 Use soft pillows to support the infant while sleeping. 5 Refrain from placing stuffed toys on the infant's bed.

1 - Refrain from smoking around the infant. 2 - Refrain from co-sleeping or bed-sharing. 5 - Refrain from placing stuffed toys on the infant's bed. The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.

A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? 1 Refuse to suture wounds 2 Follow the primary healthcare provider's instructions 3 Agree to suture wounds in the primary healthcare provider's presence 4 Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association)

1 - Refuse to suture wounds A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) is the ultimate source relative to a nurse's professional practice; a nurse may not function outside of the legal definition of nursing practice. Performing suturing, with or without supervision, conflicts with the state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act), and the nurse would be functioning outside the legal scope of nursing practice. The state board of nursing (Canada: Provincial/Territorial RN Association) does not have jurisdiction concerning this procedure.

What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position? 1 Sitting down in a chair by the client and saying, "I'm here to spend time with you." 2 Touching the client gently on the shoulder and saying, "I'm going to sit with you for a while." 3 Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me." 4 Leaving the client alone because the behavior demonstrates that the client has regressed too far to benefit from talking with the nurse

1 - Sitting down in a chair by the client and saying, "I'm here to spend time with you." "I'm here to spend time with you" accepts the client at the client's current level and allows the client to set the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive response. Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me," asks the client to reach out to the nurse; in the therapeutic relationship, the nurse must reach out to the client. Even if the client is too withdrawn to respond, the nurse's physical presence can be reassuring, so leaving the client alone is not the most appropriate choice.

The nurse has already removed a snakebite victim to a safe area. What action should the nurse take as the next priority in this situation? 1 The nurse should encourage the client to rest. 2 The nurse should remove jewelry and clothing. 3 The nurse should take photographs of the snake. 4 The nurse should call for immediate emergency assistance.

1 - The nurse should encourage the client to rest. The next priority of the nurse is to encourage the client to rest to decrease the venom circulation. The next priority for the nurse is to remove jewelry and constricting clothing. The third priority for the nurse is to call immediate emergency assistance. As a final prioritizing measure, the nurse should take digital photographs of the snake for identification.

A nurse is caring for an older adult with dementia who has been admitted in the special ward for further treatment. Which situation should the nurse address to meet the safety and security needs of the client according to Maslow's hierarchy of needs? 1 "Since my teeth hurt when I eat, I drink fruit juices and prefer a liquid diet." 2 "I do not want to talk to any stranger as I fear that they might take away my things." 3 "My blood pressure level keeps on fluctuating, although I take medications regularly." 4 "Ever since my family members came to know about my problem they are trying to avoid me."

2 - "I do not want to talk to any stranger as I fear that they might take away my things." The nurse should attend to the safety and security needs of the client by addressing the client's fear of strangers. When the client says that he/she is on liquid diet, the nurse should consider this as a possible lack of nutrition. This is a physiological need. When the client says that his/her blood pressure level fluctuates, the nurse should consider this as an example of physiological needs. When the client says that his/her family members avoid him/her as he/she has dementia, the nurse should understand this to be a love and belonging need.

A nurse is recollecting Sigmund Freud's psychoanalytical model of personality development. What is the characteristic of the oral stage? 1 "In the oral stage, the infant develops Electra complex feelings." 2 "In the oral stage, the infant realizes that he or she is a separate individual." 3 "In the oral stage, the infant changes the focus to the anal zone for pleasure." 4 "In the oral stage, the infant delays gratification to meet parental and societal expectations."

2 - "In the oral stage, the infant realizes that he or she is a separate individual." In the oral stage, the infant realizes that he or she is a separate individual. In the Oedipal stage, the infant develops an Electra complex feeling where the child fantasizes about the parent of the opposite sex as his or her first love interest. In the anal stage, the infant changes the pleasure focus to the anal zone. In the anal stage, the infant delays gratification to meet parental and societal expectations.

What statements would a nurse include in a safety promotional program to educate the parents of preschoolers? Select all that apply. 1 "Have your child sleep on his or her back or side." 2 "Teach your children physical safety rules." 3 "Allow your children to be friendly to strangers." 4 "Remove doors from unused refrigerators and freezers." 5 "Avoid instructing children to cross roads and walk in parking lots."

2 - "Teach your children physical safety rules." 4 - "Remove doors from unused refrigerators and freezers." A nurse should educate parents to teach their children about basic physical safety rules such as the proper use of safety scissors, never running with an object in their mouth or hand, and never attempting to use the stove or oven unassisted. A nurse should also instruct parents to remove doors from unused refrigerators and freezers because if a child cannot freely exit from appliances, asphyxiation can occur. Having a child sleep on his or her back or side helps to avoid the risk of sudden infant death syndrome. This advice is helpful for infants rather than preschoolers. Preschoolers should be instructed not to talk to strangers to reduce the risk of injury and stranger abduction. Preschoolers should be taught how to cross roads and walk in parking lots to acquaint them to traffic rules and lower the risk of car accidents.

The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after when? 1 12 hours 2 24 hours 3 48 hours 4 72 hours

2 - 24 hours The ovum is viable for about 24 hours after ovulation; if not fertilized before this time, it degenerates. For this reason, 12 hours, 48 hours, and 72 hours are all incorrect answers.

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning? 1 Shallow 2 Blowing 3 Slow chest 4 Modified paced

2 - Blowing Blowing forcefully through the mouth controls the strong urge to push and allows for a controlled birth of the head. A shallow breathing pattern does not help control expulsion of the fetus. Slow chest breathing is used during the latent phase of the first stage of labor; it is not helpful in overcoming the urge to push. Modified paced breathing is used during active labor when the cervix is dilated 3 to 7 cm; it is not helpful in overcoming the urge to push.

A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction? 1 Encourage the child to sing songs with the nurse. 2 Engage in parallel play while sitting next to the child. 3 Provide opportunities for the child to play with other children. 4 Use therapeutic holding when the child does not respond to verbal interactions.

2 - Engage in parallel play while sitting next to the child. Entering the child's world in a nonthreatening way by engaging in parallel play while sitting next to the child helps promote trust and eventual interaction with the nurse. Using therapeutic holding may be necessary when a child initiates self-mutilating behaviors. Singing songs with the child or providing opportunities for the child to play with other children is unrealistic at this time; playing with others is a long-term objective.

A resident primary healthcare provider in the birthing unit asks the nurse to prepare for a vaginal examination on a client with a low-lying placenta who is in early labor. What is the priority nursing action at this time? 1 Preparing an intravenous piggyback of oxytocin 2 Explaining why a vaginal examination should not be performed 3 Obtaining an internal monitor to be applied during the examination 4 Having equipment ready for a fetal scalp pH after the examination

2 - Explaining why a vaginal examination should not be performed A vaginal examination may cause separation of the placenta, resulting in hemorrhage. The nurse should discuss the situation with the resident, away from the client, because it is imperative that a vaginal examination not be performed without preparation for a cesarean birth. There is not enough data to indicate the need to stimulate labor with oxytocin. An internal monitor is contraindicated, because its placement may damage the placenta. Fetal scalp pH monitoring is contraindicated because it may damage the placenta.

The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? Select all that apply. 1 Arrange for restorative care. 2 Help the family set up home care if required. 3 Refrain from telling the family that the client is dying. 4 Know the client and family's strengths and weaknesses. 5 Arrange for church or community support for the family.

2 - Help the family set up home care if required. 4 - Know the client and family's strengths and weaknesses. 5 - Arrange for church or community support for the family. Because some dying clients prefer to be at home with the family during their last days, the nurse should help the family set up home care if required. The nurse should also know the client and family well to be able to provide client-centered care. The nurse should also arrange for church or community support to help the client and family during this difficult time. A dying client may be in pain and require hospice care, not restorative care. The nurse must maintain the trust in the nurse-client relationship and prepare the family for the client's death. The nurse should inform the family about the dying process.

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? 1 Insert a urinary retention catheter. 2 Institute measures to prevent constipation. 3 Encourage an increase in the intake of caffeine. 4 Suggest that a carbonated beverage be ingested daily.

2 - Institute measures to prevent constipation. A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence. Urinary retention catheters should not be used to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence. Caffeine acts as a diuretic and is a urinary bladder irritant; both promote urinary incontinence. Carbonated beverages irritate the urinary bladder, which promotes urinary incontinence.

An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguineous drainage from the client's left ear. Which action should the nurse take? 1 Irrigate the ear with normal saline. 2 Place a sterile pad over the external ear. 3 Gently insert a cotton-tipped swab in the ear canal. 4 Pack a cotton ball in the external meatus of the ear.

2 - Place a sterile pad over the external ear. A lowered level of consciousness indicates a potential head injury, and drainage from an ear may be cerebrospinal fluid; a sterile pad gently affixed over the ear will absorb drainage and prevent infection and can help detect the halo sign. Irrigating the ear with normal saline is contraindicated if a cerebrospinal fluid leak is suspected. Packing a cotton ball in the external meatus of the ear or inserting a cotton-tipped swab may be traumatic and may injure the ear further; also, it will obstruct free flow of drainage.

Which points have been correctly stated regarding prescriptive theories? Select all that apply. 1 Prescriptive theories do not predict the consequences. 2 Prescriptive theories address nursing interventions for a phenomenon. 3 Prescriptive theories describe the conditions under which the prescription occurs. 4 Prescriptive theories guide nursing research to develop and test specific nursing interventions. 5 Prescriptive theories are not action-oriented and do not test the validity and predictability of a nursing intervention.

2 - Prescriptive theories address nursing interventions for a phenomenon. 3 - Prescriptive theories describe the conditions under which the prescription occurs. 4 - Prescriptive theories guide nursing research to develop and test specific nursing interventions. Prescriptive theories address nursing interventions for a phenomenon. Prescriptive theories describe the conditions under which the prescription occurs. Prescriptive theories guide nursing research to develop and test specific nursing interventions. Prescriptive theories predict the consequences. Prescriptive theories are action-oriented and test the validity and predictability of a nursing intervention.

A client leaves group therapy in the middle of the session. The nurse finds the client obviously upset and crying, and the client tells the nurse that the group's discussion was too much to tolerate. What is the most therapeutic initial nursing action at this time? 1 Request kindly but firmly that the client return to the group to work out conflicts. 2 Suggest that the client accompany the nurse to a quiet place so that they can talk about the situation. 3 Ask the group leader what happened in the group session and base interventions on this additional information. 4 Respect the client's right to decline therapy at this time and report the incident to the rest of the health team members.

2 - Suggest that the client accompany the nurse to a quiet place so that they can talk about the situation. Asking the client to discuss the situation privately incorporates the principles of starting where the client is and helping the client verbalize feelings; it also facilitates the collection of additional data. The client is not ready to return to the group. Asking the group leader what happened in the group session should be done later, after the more appropriate nursing action is completed. Respecting the client's right to decline therapy accepts the client's right not to be forced back into the group; however, direct nursing intervention should be attempted at this time.

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1 Thrombocytopenia 2 Oxygen deficiency 3 Clotting factor deficiency 4 Low hemoglobin

3 - Clotting factor deficiency FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment.

A healthcare provider prescribes supplemental oral iron therapy for a child with iron-deficiency anemia. What side effect will the nurse tell the parents to anticipate? 1 Bloody stool 2 Orange urine 3 Greenish-black stool 4 Staining of the mouth

3 - Greenish-black stool Iron is excreted in the feces, and the change in color results from the insoluble iron compound excreted in the stool. Blood in the stool is associated with lower intestinal bleeding, not supplemental iron ingestion. Orange urine is not associated with supplemental iron ingestion; it occurs with phenazopyridine hydrochloride or rifampin administration. Staining of the mucous membranes of the mouth should not occur with oral administration of iron if a straw is used and the teeth are brushed immediately after administration. The teeth, not the mucous membranes, may become stained if these precautions are not taken.

A 10-year-old child who has sustained a head injury is brought to the emergency department by his parents, and a diagnosis of a mild concussion is made. What instructions should the nurse include at the time of discharge? 1 Withhold food and fluids for 24 hours. 2 Encourage outdoor play and visits with friends. 3 Arrange for a follow-up visit with the primary healthcare provider. 4 Check for changes in responsiveness every 2 hours for 2 days.

4 - Check for changes in responsiveness every 2 hours for 2 days. Signs of an epidural hematoma in children usually do not appear for 24 or more hours; parents are instructed to observe the injured child for changes in behavior and to notify the provider if they occur. If there is no nausea, food and fluids are not restricted. The child should be encouraged to rest and should be with an adult so responsiveness can be monitored. Arranging for a follow-up visit without a specific date is too vague; the child should be seen by the primary healthcare provider within 1 to 2 days of the injury.

What is the priority nursing care for a client with delirium? 1 Providing a body massage 2 Arranging for music therapy 3 Teaching relaxation techniques 4 Creating a calm and safe environment

4 - Creating a calm and safe environment A client with delirium has cognitive impairment, so the priority nursing care is to create a calm and safe environment. Providing a body massage may provide physical comfort to the client but is not the priority nursing care. Arranging for music therapy may temporarily comfort the client but is not the priority nursing care. Teaching relaxation techniques is difficult for a client with delirium because the client is cognitively impaired.

Which action by the nurse constitutes constructive feedback for the delegatee? 1 Providing verbal attacks on feedback 2 Providing feedback to individual delegatee 3 Providing nonspecific feedback about the behavior 4 Providing open feedback about specific strategies for change

4 - Providing open feedback about specific strategies for change The best strategy is to provide open, honest, and constructive feedback. The feedback should be about work-related performance and specific strategies for change in the quality of performance. A verbal attack on a delegatee does not produce effective change and could undermine any long-term working relationship. Providing feedback to an individual delegatee as satisfactory may diminish the credibility of the nurse. Creating a work environment in which specific feedback about performance is provided is the best strategy for shaping the future behavior of the delegatee.

A nursing student is listing examples of healthcare services. Which scenario is an example of restorative care? 1 Performing radiological procedures on a client who has sustained a heart attack 2 Monitoring the blood pressure of an older adult with insomnia and hypertension 3 Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby 4 Visiting a private residence to perform maggot-aided debridement therapy of a client's wound

4 - Visiting a private residence to perform maggot-aided debridement therapy of a client's wound Visiting a client's residence to perform maggot-aided wound debridement is an example of restorative care. Performing radiological procedures on a client who has sustained a heart attack is an example of secondary acute care. Monitoring the blood pressure of an older adult with insomnia and hypertension is an example of preventive care. Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby is an example of primary care.

A male client is preparing to leave the hospital and return to college. When saying goodbye he hugs the nurse and kisses her on the cheek. What is the most appropriate response by the nurse? 1 Hug the client in return. 2 Smile at the client but say nothing. 3 Encourage him to visit periodically. 4 Wish him well with his future studies.

4 - Wish him well with his future studies. An explicit termination statement is most appropriate; offering an expression of well-wishes sets an optimistic, positive tone while maintaining the nurse-client relationship. A repeat of the physical contact should be avoided because it may precipitate anxiety in the client or be interpreted as a desire to change the relationship from professional to personal. Smiling and saying nothing may indicate acceptance of the physical exchange and blurs boundaries. Encouraging the client to visit periodically is nontherapeutic because it indicates an ongoing rather than a terminating relationship.