Nursing 166 NCLEX Qs

1. The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? a) "I swim three times a week." b) "I have stopped smoking cigars." c) "I drink hot chocolate before bedtime." d) "I read for 40 minutes before bedtime." - answer-1) C - Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20-to 30-minute walk, swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest. - Test-Taking Strategy: Note the strategic words need for further teaching . These words indicate a negative event query and ask you to select an option that is an incorrect statement. Options A, B, and D are positive statements indicating that the client understands the methods of improving sleep. 2. Geriatric Nursing Exam Questions about a visiting nurse who observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? a) Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." b) Suggest to the client and daughter-in-law that they consider a nursing home for the client. c) Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. d) Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center. - answer-2) D - Geriatric Nursing Exam Questions Rationale: Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option C is not appropriate and is passive in terms of advocacy. Option B suggests committing the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option A is incorrect and judgmental. - Test-Taking Strategy: Note the strategic words most important. Using principles related to the ethical and legal responsibility of the nurse and knowledge of the nurse's role will direct you to the correct option. Option A is a nontherapeutic statement, option B is a premature action, and option C avoids the situation. 3. The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? a) Crusting b) Wrinkling c) Deepening of expression lines d) Thinning and loss of elasticity in the skin - answer-3) A - Rationale: The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin would indicate a potential complication. - Geriatric Nursing Exam Questions Test-Taking Strategy: Note the subject , a potential complication. Think about the normal physiological changes that occur in the aging process to direct you to the correct option. 4. The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? a) Check for medication interactions. b) Determine whether there are medication duplications. c) Call the prescribing health care provider (HCP) and report polypharmacy. d) Determine whether a family member supervises medication administration. - answer-4) B - Rationale: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected. - Test-Taking Strategy: Note the strategic word first . Also note that the nurse is visiting the client for the first time. Options A, C, and D should be done after possible medication duplication has been identified. 5. The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological change(s) the nurse expects to note? Select all that apply. a) Increased heart rate b) Decline in visual acuity c) Decreased respiratory rate d) Decline in long-term memory e) Increased susceptibility to urinary tract infections f) Increased incidence of awakening after sleep onset - answer-5) B, E, F - Geriatric Nursing Exam Questions Rationale: Anatomical changes to the eye affect the individual's visual ability, leading to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, age-related change. Older persons experience an increased incidence of awakening after sleep onset. - Test-Taking Strategy: Focus on the subject , normal age-related changes. Read each characteristic carefully and think about the physiological changes that occur with aging to select the correct items. A 72 year old client is admitted to a long term care facility with impaired mobility and poor nutritional status after a CVA. Which of the following is an appropriate action for the LPN assigned to his care? 1- Perform an initial skin assessment 2- Delegate routine skin care to the nursing assistant. 3- Massage redenned areas noted on the client's bony prominences. 4- Assist the RN to develop a q2 hour turning schedule. - answer-4 A client diagnosed with pneumonia recently returned to an assisted living facility after being treated in the hospital with IV antibiotics. The client begins having consistent foul smelling diarrhea and is diagnosed with clostridium difficile. Which statement by the client indicates further teaching is necessary? 1- "I need to wash my hands once a day." 2- "I need to drink at least six glasses of water a day." 3- "clostridium difficile is highly contagious." 4- "Care providers will wear protective clothing in my room." - answer-1 A client with Alzheimer's disease who is typically pleasant and cooperative returns to the nursing home after repair of a broken femur resulting from a fall. Which of the following findings would indicate to the nurse that the client was experiencing pain? Select all that apply. 1-The client's teeth are clenched as he moves to a chair. 2- The client hits at the CENA as she attempts to undress him for his bath. 3- The client is tense and fidgeting during meal time. 4- The client groans when repositioned in bed. 5- The client's resting respiratory rate is 16. 6- The client advances his walker and then moves his feet forward one at a time. - answer- A home health nurse visits a client 2 weeks after discharge from the hospital. The client experienced an acute myocardial infarction and subsequent heart failure. Home medications are listed in the exhibit. Which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in legs - answer-The nurse would be most concerned with the client's report of muscle cramps in the legs. This could be a sign of hypokalemia caused by use of the diuretic furosemide or possibly a reaction from the statin medication atorvastatin. Hypokalemia may manifest as muscle cramps, weakness, or paralysis and typically starts with the leg muscles. Hypokalemia could be dangerous in this client due to possible arrhythmias in the presence of existing cardiac dysfunction. The client may need to be started on supplemental potassium and a high-potassium diet if the serum potassium level is low. If the potassium level is normal, atorvastatin may be responsible for muscle cramps. (Option 1) Bruising, especially on the upper extremities, is common with the use of antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor for other, more severe signs of bleeding, such as blood in the stool. (Option 2) The myocardial infarction and heart failure have most likely reduced the client's functional capacity and can cause fatigue. Beta blockers such as metoprolol can also cause fatigue. This will improve with time, and the nurse should talk to the client about possible cardiac rehabilitation. (Option 3) Feeling depressed is common after an acute health-related event such as a myocardial infarction. The client needs to be evaluated further and may need an antidepressant. However, feelings of depression are not immediately life-threatening unless the client exhibits suicidal ideation. Educational objective: The nurse should recognize muscle cramps in the legs as a possible sign of hypokalemia in the client taking diuretics. Muscle cramps should be reported to the health care provider in anticipation of checking a potassium level, adding a potassium supplement, and instructing the client to eat potassium-r A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying: A. "Don't worry about the medication's name if you can identify it by its color and shape." B. "Unless you have severe side affects, don't worry about the minor changes in the way you feel." C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." D. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications." - answer-C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." Rationale: The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. A major concept underlying the process of Root Cause Analysis is that a majority of medical errors: 1- are related to increased technology and lack of sufficient training 2- result from individual human error 3- are caused by a faulty system or process 4- result from short staffing and time constraints - answer-3 A new nurse at the long term care facilty is interested in using the PAIN AD scale on the dementia unit. To effectively use the scale, which action should the nurse take first? 1- Identify each client's history for a diagnosis of arthritis. 2- Examine the client's medication record for prescribed pain meds. 3- Ask the client's roommate if the client has been moaning in his sleep. 4- Observe clients in their resting state for indications of pain first. - answer-4 A new nurse is being oriented as an LPN to a sub acute rehabilitation facility. The nurse recognizes that physician care in a nursing home is based on which of the following statements? 1) Nursing home residents today require fewer visits by physicians. 2) Federal law mandates that physicians visit their patients on a bi-annual basis. 3) Physician services are required to be available as needed 7 days a week, 24 hours a day. 4) Physicians are required to respond to the medical needs of residents within 1 week of notification. - answer-3 A nurse is caring for an 86 year old female recently admitted to the skilled care facility after a left hip fracture with repair. During report the nurse learns the client is weak on the left side and has a slightly unsteady gait and uses a walker for ambulation. Which action by the nurse would best help prevent complications? 1- Use a Hoyer lift for all transfers. 2- Ensure participation in physical therapy and rehab activities. 3- Assess the client's gait and transfer ability every two hours. 4- Encourage the client to choose foods rich in carbohydrate. - answer-2 A nurse is taking care an 81 year old male who recently experienced a cerebrovascaular accident (CVA) that damaged the temporal lobe of the brain. The nurse would expect this patient to need assistance with which of the following? 1- Reasoning 2- Temperature Regulation 3- Communication 4- Coordination - answer-3 A nurse is working with patients in a long term care setting. Which of the following patients is at the highest risk for falling? 1- A patient with heart failure who requires a 2-person assist for wheelchair transfers. 2- A patient that ambulates well with a walker and gets up to void several times at night. 3- A patient's who is blind and has two side-rails up while in bed. 4- A patient with Parkinson's disease that holds onto furniture while ambulating in their room. - answer-4 A nurse preparing to provide a client with Diphenhydramine (Benadryl) 25 mg orally would include which of the following statements in the teaching? 1- "Many people who take this medication report that is causes itchiing." 2- "Sometimes this medication can cause you to go to the bathroom more often than usual." 3- "This medication may make your mouth feel dry." 4- "This is a very low dose, so you may want to ask the doctor to increase it tomorrow." - answer-3 A paraplegic patient, paralyzed from the waist down, is newly diagnosed with a stage II pressure ulcer on the left hip. In planning care for this patient the nurse would include which of the following interventions? (Select all that apply) 1- Encourage a high protein diet 2- Turn the patient every 6 hours 3- Use hot water and maximize soap for bathing needs 4- Limit the number of linens between the patient and mattress 5- Provide a trapeze over the patient's bed to allow self-repositioning - answer-1-4-5 A patient is newly diagnosed with iron-deficiency anemia. Which of the following meal selections indicates the patient understands important dietary modifications? 1- A hot d