Nursing Leadership and Management NCLEX Questions | Questions and Answers with complete solution

A registered nurse reviews a plan of care developed by a nursing student for a client with depression and notes a nursing diagnosis of impaired nutrition: less than body requirements. The registered nurse asks the student to revise the plan if which incorrect intervention is documented? a) offer small, high-calorie, high protein snacks frequently throughout the day and evening b) offer high protein, high-calorie fluids frequently throughout the day and evening c) remain with the client during meals d) complete the food menu for the client during the depressed period - D - The client should be asked which foods or drinks she likes, and consultation with a dietitian also may be done. The client is more likely to eat if the client has selected the foods and is given foods that she likes. Options A, B, and C are appropriate interventions for the client with depression with this nursing diagnosis. A registered nurse reviews a plan of care developed by a nursing student for client with paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse asks the nursing student to revise the plan if which incorrect intervention is documented? a) sit with the client and hold the client's hand b) avoid a warm approach when working with the client c) use simple and clear language when speaking to the client d) diffuse angry and hostile verbal attacks with a nondefensive stand - A - When caring for a paranoid client, the nurse must avoid any physical contact and should not touch the client. The nurse should ask the client's permission if touch is necessary because touch may be interpreted as a physical or sexual assault. The nurse would use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse's intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. A matterof-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a nondefensive stand. The anger that a paranoid client expresses is often displaced, and when the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and nonjudgmental attitude provides an attitude in which feelings can be explored more easily.A registered nurse is discussing the characteristics of anorexia nervosa with a nursing student. The registered nurse determines that the nursing student needs to further research this disorder if the student states that which of the following is a characteristic of anorexia nervosa? a) personal relationships tend to become more superficial and distant b) social contacts are avoided because of the fear of being invited to eat and being discovered c) the client is being preoccupied with food and meal planning, especially for others d) the client will usually keep her weight near normal - D