NCLEX QUESTION TRAINER EXPLANATIONS TEST 4

.......................................................................................... N C L EX Q U E S T I O N T R A I N E R Nursing .......................................................................................................................................................................................................................................................................... 27 6. The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program 7. A client received six units of regular insulin three hours ago. The nurse would be MOST concerned if which of the following was observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria. Strategy: “MOST concerned” indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct–regular insulin peaks in two to four hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia 8. The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, “I just don’t feel good.” Which of the following actions, if taken by the nurse, is BEST? 1. The nurse talks with the client about how he is feeling. 2. The nurse instructs the nursing assistant to sit with the client while he eats. 3. The nurse contacts the physician to obtain an order for an antacid. 4. The nurse evaluates the most recent vital signs recorded in the chart. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct–assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now