NCLEX Client Needs Lippincott Prep-U

A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest? a) Take stress-management classes. b) Change jobs. c) Spend more time with his family. d) Leave work at work. - Take stress management class. Rationale: The nurse should suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach him how to manage stress more effectively. The client may not have to leave a job he enjoys. The information provided by the client doesn't indicate that spending too little time with his family and taking his job home with him contribute to the client's stress. A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ice cream. b) ground beef patties. c) fresh orange slices. d) steamed broccoli. - ground beef patties. Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair. A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true? a) The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye. b) The client can read at a distance of 30′ (9 m) what a person with normal vision can read at a distance of 40′. c) The client can read the entire vision chart at a distance of 40′ (12 m). d) The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. - The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Rationale: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read A nurse is providing care for a pregnant 16-year-old. The client says that she is concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: a) "The prenatal vitamins should ensure the baby gets all the necessary nutrients." b) "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." c) "Now isn't a good time to begin dieting because you are eating for two." d) "Let's explore your feelings further." - "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." Rationale: Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this issue with the client. The client isn't eating for two; this belief is a misconception. Exploring feelings helps the client understand her concerns, but the nurse also needs to make the client aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or developing fetus needs; they work in conjunction with a balanced diet. A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? a) Evaluation for signs and symptoms of increased intracranial pressure (ICP) b) Lung auscultation and measurement of vital capacity and tidal volume c) Evaluation of nutritional status and metabolic state d) Evaluation of pain and discomfort - Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities. An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals blood pressure (BP) 160/78, heart rate (HR) 102 beats per minute, and respiration rate 32 breaths per minute with audible wheezing. Which of the following is the nurse's priority action? a) Administer 100% oxygen via mask b) Assess the site to remove the stinger c) Assist the client to lie down d) Assess the client's airway - Assess the client's airway Explanation: All of the answers may need to be done for this client, but the initial priority action for any client with an elevated respiratory rate and wheezing is to assess and maintain the airway. When integrating the concepts underlying the cognitive-behavioral model into a client's plan of care, the nurse should focus on which of the following areas? a) Reduction of bodily tensions and stress management. b) Analysis of fears and barriers to growth. c) Substitution of rational beliefs for self-defeating thinking and behaving. d) Insight into unconscious conflicts and processes. - Substitution of rational beliefs for self-defeating thinking and behaving. Explanation: Substituting rational beliefs is a major goal when using cognitive-behavioral models, which focus more on thinking and behaviors than feelings. Unconscious processes are the focus of psychoanalytic models. Analysis of fears and barriers to growth are the focus of developmental models. Tension and stress are targets of the stress models. Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? a) Continue previous contraceptive use even if you're experiencing amenorrhea. b) Amenorrhea is irreversible. c) This medication may result in heightened libido. d) Incidence of dysmenorrhea may increase while taking this drug. - Continue previous contraceptive use even if you're experiencing amenorrhea. Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and the depressant effect generally decreases libido. A staff nurse on the mental health unit tells the nurse manager that kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway. What is the best reply by the nurse manager? a) "You sound really frustrated. Let's talk about the meaning of their behavior." b) "These children are more likely to have problems with depression and anxiety disorder as adults." c) "My experience hasn't been that negative. Let's see what the other staff members think; maybe I'm wrong." d) "You really sound burned out. Do you have a vacation coming up soon?" - "You sound really frustrated. Let's talk about the meaning of their behavior Explanation: The nurse manager needs to focus on the frustration that the nurse is expressing. Additionally, the nurse manager needs to correct any misinformation or misinterpretation that the staff nurse has. Saying that the nurse sounds burned out and asking about a vacation does not focus on the nurse's frustration or address the inaccuracy of the nurse's statement. There is no evidence to suggest that children with conduct disorder have more than the average adult's risk of depression or anxiety. Therefore, this response is inaccurate and inappropriate. Anecdotal information from personal experience does not supply the nurse with accurate, reliable information. (less) A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation? a) Lochia alba b) Minimal afterpains when nursing c) A fundus palpable at the umbilicus d) A nonpalpable fundus in the abdomen - A fundus palpable at the umbilicus Explanation: A fundus palpable at the umbilicus 10 days postpartum is abnormal. The fundus is typically at this level 1 hour after delivery. By the 10th day postpartum, the uterus should no longer be palpable. Lochia alba is normal at 10 days postpartum. Minimal afterpains when nursing is a normal finding. A fourth heart sound (S4) indicates a: a) dilated aorta. b) normally functioning heart. c) decreased myocardial contractility. d) failure of the ventricle to eject all blood during systole. - failure of the ventricle to eject all blood during systole. Explanation: An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. She doesn't hear an S4 in a normally functioning heart. A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? a) At bedtime. b) At the time scheduled. c) All at one time. d) Two hours before mealtime. - At the time scheduled. Explanation: While the client is hospitalized for adjustment of medication, it is essential that the medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness. For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one time, for optimum effectiveness. A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: a) Check on the client at regular intervals to ascertain the need to use the bathroom. b) Put all four side rails up on the bed. c) Request that the client's roommate put the call light on when the client is attempting to get out of bed. d) Ask the unlicensed personnel to place restraints on the client's upper extremities. - Check on the client at regular intervals to ascertain the need to use the bathroom. Explanation: Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written order from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety. A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family doesn't have much money and her dad just got laid off from his job. Which of the following would be the nurse's most appropriate action? a) Ask the client if she has a job and the amount of income earned. b) Instruct the client in methods for low-cost, highly nutritious meal preparation. c) Refer the client to a social worker for enrollment in a food assistance program. d) Determine whether the client qualifies for local assistance programs. - Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program. Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's need for additional funds for food. Determining whether the client qualifies for assistance is part of the role of the social worker, not the nurse. Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance. Which of the following changes are associated with normal aging? a) The dermis becomes highly vascular and assists in the regulation of body temperature. b) The outer layer of skin is replaced with new cells every 3 days. c) Subcutaneous fat and extracellular water decrease. d) Collagen becomes elastic and strong. - You selected: Subcutaneous fat and extracellular water decrease. Correct Explanation: With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3 to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age. (less) To which of the following unlicensed assistive personnel should the nurse assign a male Muslim client who needs complete morning care? a) Jill, who has four clients requiring partial morning care. b) Jim, who has five clients requiring partial morning care. c) Joe, who has one client requiring complete morning care. d) Mary, who has two other clients requiring complete morning care. - You selected: Joe, who has one client requiring complete morning care. Correct Explanation: The nurse should assign the Muslim male client who needs morning care to Joe. Muslim men cannot be cared for by female nurses. The nurse must also consider work load and Joe has the lightest amount. (less) -Select all answer choices that apply. The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply. a) To ensure efficient and accurate communication. b) To make data entry into a computerized health record easier. c) To ensure client safety. d) To prevent medication errors. e) To make it easier for clients to understand the medication orders. - d) To prevent medication errors. a) To ensure efficient and accurate communication. c) To ensure client safety. Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication orders or to make data entry easier. The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue? a) "I spend one weekend day a week resting in bed while my husband cares for the children." b) "I sleep for 8 to 10 hours every night so that I'll have the energy to care for my children during the day." c) "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." d) "I get up early in the morning and get all my household chores completed before my children wake up." - You selected: "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." Explanation: Regularly scheduled rest periods during the day along with 8 to 10 hours of sleep at night helps relieve the fatigue, pain, and stiffness associated with rheumatoid arthritis. Even with mild rheumatoid arthritis, the client may find it difficult to perform activities of daily living without some rest periods. Spending 1 day a week in bed to relieve fatigue does not adequately manage the disease. The client must recognize the need for rest before feeling exhausted because overexertion can cause exacerbations. In addition, prolonged periods of inactivity can increase joint stiffness and pain. Getting up early to do household chores before the children are awake does not allow for adequate rest. (less) Which of the following behaviors by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fistula? a) Sucking attempts that are too poorly coordinated to be effective. b) Projectile vomiting that occurs after drinking 4 oz (118 ml). c) Coughing, choking, and cyanosis that occur after several swallows of formula. d) Sleeping that occurs after taking 10 ml of formula with an inability to be stimulated to take more. - You selected: Coughing, choking, and cyanosis that occur after several swallows of formula. Explanation: The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth. Poor rooting reflexes and sucking attempts are typical of infants with neurologic dysfunction or related to reflex depression secondary to medication given to the mother during labor. Projectile vomiting is typical of infants with neurologic dysfunctions. This reflex may also be depressed by medication given to the mother during labor. Falling asleep after taking little formula is characteristic of an infant who becomes exhausted with the exertion of feeding, commonly caused by a cardiac anomaly. Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? a) Weakness in the extremities. b) Sudden bursts of energy. c) Muscle tremors. d) Double vision. - You selected: Sudden bursts of energy. Explanation: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS. A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend? a) Drinking liquids with dry foods b) Keeping crackers at the bedside to eat before getting out of bed c) Drinking water with every meal d) Eating three large meals per day - You selected: Keeping crackers at the bedside to eat before getting out of bed Explanation: The nurse should advise the client to keep crackers at the bedside because eating dry crackers before getting out of bed and before the stomach becomes empty helps prevent nausea. Drinking water with every meal does not alleviate nausea. Eating six small meals per day, rather than three large meals, prevents nausea by preventing the stomach from becoming empty. Drinking liquids with dry food increases nausea. The client should be instructed to wait at least 30 minutes to consume liquids after eating dry food. A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide? a) "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." b) "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." c) "Administer desmopressin while the suspension is cold." d) "You won't need to monitor your fluid intake and output after you start taking desmopressin." - You selected: "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." Explanation: The nurse should advise the client that desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and get adequate fluid replacement. The parents of a 12-year-old girl ask why their non-sexually active daughter should receive the human papillomavirus (HPV) vaccine. The nurse should tell the parents: a) "The vaccine is most effective against cervical cancer if given before becoming sexually active." b) "Parents are never sure when their child might become sexually active." c) "If your daughter is sexually assaulted, she may be exposed to HPV." d) "HPV is most common is teens and women in their late twenties." - You selected: "The vaccine is most effective against cervical cancer if given before becoming sexually active." Explanation: Vaccines are preventative in nature and ideally given before exposure. Focusing on the benefits of cancer prevention is most appropriate, as opposed to discussing with parents the potential that their child may become sexually active without their knowledge. It is true HPV is most common in adolescents and women in their late twenties, but parents still may not perceive that their child is at risk. Discussing the possibility of exposure through assault raises fears and does not focus on prevention. A client is brought to the emergency department (ED) after ingesting an unknown quantity of antidepressant medication and sleeping pills. A family member tells the nurse that the client has recently experienced several significant losses. The client is stabilized in the ED and transferred to a psychiatric unit. What is the nurse's best response when the client sobs uncontrollably and refuses to come to breakfast? a) "I will bring you some medication to help settle your anxiety." b) "I know you are feeling sad now, but it will get better with time." c) "Your feelings are real. I'll bring your breakfast and sit with you if you want." d) "Come join the others. It will be good to get into the routine of the unit." - You selected: "Your feelings are real. I'll bring your breakfast and sit with you if you want." Explanation: Acknowledging the client's feelings is validating and builds rapport. The offer to bring breakfast and sit with the client is the most therapeutic response since the client is adjusting to the unit and requires considerable assessment. Encouraging someone who is in a poor emotional state to join others is not productive to the client or the milieu. Acknowledging the client's sadness is part of validating feelings; however, this response names the feelings for the client and provides platitudes that are not therapeutic. Finally, offering anti-anxiety medication simply because someone is tearful is not an acceptable intervention, and closes down what is a potentially a helpful opportunity for ventilation, validation, assessment, and intervention. A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values? a) Increased serum amylase and lipase levels. b) Decreased glucose level. c) Increased calcium level. d) Decreased urine amylase level. - Increased serum amylase and lipase levels. Explanation: Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels. (less) A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: a) Delay assessment until client's respiratory distress is resolved. b) Focus assessment on the respiratory system and distress. c) Complete a comprehensive physical examination. d) Conduct a complete health history. - Focus assessment on the respiratory system and distress. Explanation: During an episode of acute respiratory distress, it is important that the nurse focus the assessment on the client's respiratory system and distress to quickly address the client's problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the client's condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment. A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis should be the highest priority? a) Impaired physical mobility b) Disturbed body image c) Risk for injury related to unsteady gait d) Deficient fluid volume (hemorrhage) - Deficient fluid volume (hemorrhage) Explanation: Deficient fluid volume(hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Risk for injury related to unsteady gait isn't indicated in this situation. Disturbed body image isn't a concern because the adolescent doesn't have a visible injury. Although the adolescent may be placed on bed rest for 5 to 7 days, Impaired physical mobility isn't the priority nursing diagnosis. (less) The nurse is caring for clients on an impatient psychiatric unit. Which client with obsessive-compulsive disorder is ready to be considered for discharge? a) The client who showers 3 instead of 10 times per day. b) The client who behaves in an outwardly normal manner. c) The client who willingly takes medication. d) The client who has obsessions but not compulsions. - The client who showers 3 instead of 10 times per day. Explanation: A decrease in compulsive behavior is an indication that anxiety has decreased and the client is better able to cope with his feelings of anxiety, thus decreasing the need to shower. The client who takes his medication may not have a decrease in obsessions or compulsive behavior. The client who has obsessions can experience interference in normal routine, social, and occupational functioning. The ability to behave in an outwardly normal manner does not indicate that the client's obsessions and compulsions have decreased. Obsessions and even some compulsions can be hidden from others. (less)