NCLEX-PN Exam Fundamentals V2
• A client has just returned to the room after having a mammogram. The client is teary and
in a shaky voice says to the nurse, "The radiology techniciantold me it looks really bad - the
tumor in my breast is very large." Which is thebest response by the nurse.
A. "I can see that you are very upset. Let's talk about what happened."
B. "I'll report the technician to the head of the radiology department."
C. "The technician never should have said that to you."
D. "Your health care provider will discuss treatment options with you.": CorrectAnswer: A. "I
can see that you are very upset. Let's talk about what happened."
Acknowledging that the client is upset conveys concern and understanding on thepart of the
nurse and helps establish a therapeutic dialogue.
The client can vent feelings and discuss fears because the nurse provides the opportunity to
talk about what happened (focusing and listening.) This action also establishes interpersonal
sensitivity and helps the nurse relate therapeutically to theclient. Clients who feel threatened or
injured by their medical condition(s) need to feelsafe and supported. The nurse is in a unique
position to provide the nurturing and caring that clients need as they cope with medical
diagnoses and difficult situations.
[Option B: "I'll report the technician to the head of the radiology department."} This is not an
appropriate response; the proper chain of command would have the nurse report the event to a
supervisor.
[Option C: "The technician never should have said that to you."] This statement maybe true, but
it does not facilitate a dialogue about the client's feelings and fears. [Option D: "Your health
care provider will discuss treatment options with you."] This response does not address the
client's feelings or what happened during the mammogram.
Educational Objective:
Therapeutic communication techniques such as acknowledgment of feelings, focus- ing, and
listening can help establish a dialogue and relationship with a client that is protective,
supportive, and caring.
• A legally blind client is being prepared to ambulate 1 day after an appen- dectomy. What is
the most appropriate action by the nurse?
,A. Arrange for the client's service dog to come to the health care facility assoon as possible.
B. Describe the environment in detail so the client can ambulate safely with acane.
C. Instruct the unlicensed assistive personnel to walk beside the client andlead by the hand.
D. Walk slightly ahead of the client with the client's hand resting on the nurse'selbow.: Correct
Answer: D. Walk slightly ahead of the client with the client's hand resting on the nurse's
elbow.
On the first postoperative day, the nurse assists the client with ambulation to evaluatealertness,
pain level, signs of orthostatic hypotension, problems with gait or mobility,and ability to
ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use
of assistive aids (eg, sighted guides, canes, guide dogs).Clients who used any ambulatory
assistive aids before surgery require postoperativeevaluation prior to ambulatory independence.
When walking with a client who is legally blind, the nurse used the sighted-guide technique
by walking slightly aheadof the client with the client holding the nurse's elbow. The nurse
should describe theenvironment while ambulating the client.
Incorrect Answers
[Answer A: Arrange for the client's service dog to come to the health care facility as soon as
possible.] The service dog may be brought to the hospital to assist in ambulation once the nurse
has determined the client can ambulate safely.
[Answer B: Describe the environment in detail so the client can ambulate safely witha cane.]
After the evaluation by the nurse, the client may be allowed to use a caneto ambulate around
the nursing unit.
[Answer C: Instruct the unlicensed assistive personnel to walk beside the clientand lead by the
hand.] Instructing the unlicensed to ambulate the client is an
inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing
assessment is required to determine if the client is able to ambulate safely.
Educational Objective:
When ambulating a client who is legally blind, the nurse uses the sighted-guidetechnique by
walking slightly ahead with the client holding the nurse's elbow.
,• A client on hospice home care is taking sips of water but refusing food.Family members
appear distressed and insist that the personal care worker"force feed" the client. What is the
priority nursing action?
A. Explain to the family that this is a normal physiological response to dying.
B. Explore the family's thoughts and concerns about the client's refusal offood.
C. Recommend a feeding tube.
D. Tell the family that "force feeding" the client could cause the client to choke on the food.:
Correct Answer: B. Explore the family's thoughts and concerns about the client's refusal of
food.
When a terminally ill person refuses food, family members often become upset andfrustrated in
their roles of nurturers and caregivers; they may feel personally rejected.Refusal of food is
associated with "giving up" and is a reminder that their loved oneis dying. It is not uncommon
for family members to believe that a client would get stronger by eating instead of refusing
food.
The registered nurse needs to explore family members' concerns and fears and listen as they
express their feelings. The nurse can help them identify other ways toexpress how they care.
The nurse should also provide education about the effects of food and water during all stages
of the illness.
[Answer A. Explain to the family that this is a normal physiological response to dying.]Families
and caregivers need to understand the effects of food and water in all stages of a terminal
illness; however, it is more important to first explore the family'sfeelings and concerns.
[Answer C: Recommend a feeing tube.] Although it is not unusual for a client to beadmitted to
hospice with a feeding tube already in place, tubes are generally not placed after a client
begins receiving hospice services.
[Answer D: Tell the family the "force feeding" the client could cause the client to chokeon the
food.] This is a true statement, but it is not the priority nursing action.
Educational Objective:
It is very common for family members to become distressed when a terminally ill loved one
refuses food. The nurse needs to explore their fears and concerns and help them identify other
ways to express how they care.
• Before examining the infant of a Mexican American mother, the nurse compliments the
child's outfit. The mother becomes visibly distressed. Whatis the best next action for the nurse
, to take?
A. Ask the mother's permission to touch the child's hand
B. Interview the mother about the reason for bringing the child to the clinic
C. Reassure the mother that there is no reason for distress
D. Suggest postponing the examination until the mother calms down: Correctanswer: A. Ask
the mother's permission to touch the child's hand.
In Latin American culture, an illness called "mal de ojo" (evil eye) is believed to be caused
when a stranger or someone perceived as powerful admires or complimentsa child. The "illness,"
or "curse," is usually manifested by vomiting, fever, and crying.The mal de ojo curse can be
broken if the admirer touches the child while speakingto the child immediately afterward.
Mexican American mothers may worry when strangers compliment their babies without
touching them. To protect against mal deojo, the child may wear charms or beaded bracelets.
If the child is believed to be afflicted with mal de ojo, the parents may consult a traditional
healer, or curandero, who may perform rituals meant to cure the child ofthe curse.
Incorrect Answers
[Option B. Interview the mother about the reason for bringing the child to the clinic.] Asking
the mother about the reason for bringing the child to the clinic will not relieve the mother's
distress.
[Option C. Reassure the mother that there is no reason for distress.] This response is
nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness.
[Option D. Suggest postponing the examination until the mother calms down.] Postponing the
examination does not address the cause of the mother's distress.
Educational Objective:
Many Latin Americans beleive in "mal de ojo," or "evil eye," a cultural belief in
an illness thought to be manifested in children by vomiting, fever, and crying. It is
believed to be caused when a stranger admires a child without touching the child atthe same
time or immediately afterward.
• A client has just returned to the room after having a mammogram. The client is teary and
in a shaky voice says to the nurse, "The radiology techniciantold me it looks really bad - the
tumor in my breast is very large." Which is thebest response by the nurse.
A. "I can see that you are very upset. Let's talk about what happened."
B. "I'll report the technician to the head of the radiology department."
C. "The technician never should have said that to you."
D. "Your health care provider will discuss treatment options with you.": CorrectAnswer: A. "I
can see that you are very upset. Let's talk about what happened."
Acknowledging that the client is upset conveys concern and understanding on thepart of the
nurse and helps establish a therapeutic dialogue.
The client can vent feelings and discuss fears because the nurse provides the opportunity to
talk about what happened (focusing and listening.) This action also establishes interpersonal
sensitivity and helps the nurse relate therapeutically to theclient. Clients who feel threatened or
injured by their medical condition(s) need to feelsafe and supported. The nurse is in a unique
position to provide the nurturing and caring that clients need as they cope with medical
diagnoses and difficult situations.
[Option B: "I'll report the technician to the head of the radiology department."} This is not an
appropriate response; the proper chain of command would have the nurse report the event to a
supervisor.
[Option C: "The technician never should have said that to you."] This statement maybe true, but
it does not facilitate a dialogue about the client's feelings and fears. [Option D: "Your health
care provider will discuss treatment options with you."] This response does not address the
client's feelings or what happened during the mammogram.
Educational Objective:
Therapeutic communication techniques such as acknowledgment of feelings, focus- ing, and
listening can help establish a dialogue and relationship with a client that is protective,
supportive, and caring.
• A legally blind client is being prepared to ambulate 1 day after an appen- dectomy. What is
the most appropriate action by the nurse?
,A. Arrange for the client's service dog to come to the health care facility assoon as possible.
B. Describe the environment in detail so the client can ambulate safely with acane.
C. Instruct the unlicensed assistive personnel to walk beside the client andlead by the hand.
D. Walk slightly ahead of the client with the client's hand resting on the nurse'selbow.: Correct
Answer: D. Walk slightly ahead of the client with the client's hand resting on the nurse's
elbow.
On the first postoperative day, the nurse assists the client with ambulation to evaluatealertness,
pain level, signs of orthostatic hypotension, problems with gait or mobility,and ability to
ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use
of assistive aids (eg, sighted guides, canes, guide dogs).Clients who used any ambulatory
assistive aids before surgery require postoperativeevaluation prior to ambulatory independence.
When walking with a client who is legally blind, the nurse used the sighted-guide technique
by walking slightly aheadof the client with the client holding the nurse's elbow. The nurse
should describe theenvironment while ambulating the client.
Incorrect Answers
[Answer A: Arrange for the client's service dog to come to the health care facility as soon as
possible.] The service dog may be brought to the hospital to assist in ambulation once the nurse
has determined the client can ambulate safely.
[Answer B: Describe the environment in detail so the client can ambulate safely witha cane.]
After the evaluation by the nurse, the client may be allowed to use a caneto ambulate around
the nursing unit.
[Answer C: Instruct the unlicensed assistive personnel to walk beside the clientand lead by the
hand.] Instructing the unlicensed to ambulate the client is an
inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing
assessment is required to determine if the client is able to ambulate safely.
Educational Objective:
When ambulating a client who is legally blind, the nurse uses the sighted-guidetechnique by
walking slightly ahead with the client holding the nurse's elbow.
,• A client on hospice home care is taking sips of water but refusing food.Family members
appear distressed and insist that the personal care worker"force feed" the client. What is the
priority nursing action?
A. Explain to the family that this is a normal physiological response to dying.
B. Explore the family's thoughts and concerns about the client's refusal offood.
C. Recommend a feeding tube.
D. Tell the family that "force feeding" the client could cause the client to choke on the food.:
Correct Answer: B. Explore the family's thoughts and concerns about the client's refusal of
food.
When a terminally ill person refuses food, family members often become upset andfrustrated in
their roles of nurturers and caregivers; they may feel personally rejected.Refusal of food is
associated with "giving up" and is a reminder that their loved oneis dying. It is not uncommon
for family members to believe that a client would get stronger by eating instead of refusing
food.
The registered nurse needs to explore family members' concerns and fears and listen as they
express their feelings. The nurse can help them identify other ways toexpress how they care.
The nurse should also provide education about the effects of food and water during all stages
of the illness.
[Answer A. Explain to the family that this is a normal physiological response to dying.]Families
and caregivers need to understand the effects of food and water in all stages of a terminal
illness; however, it is more important to first explore the family'sfeelings and concerns.
[Answer C: Recommend a feeing tube.] Although it is not unusual for a client to beadmitted to
hospice with a feeding tube already in place, tubes are generally not placed after a client
begins receiving hospice services.
[Answer D: Tell the family the "force feeding" the client could cause the client to chokeon the
food.] This is a true statement, but it is not the priority nursing action.
Educational Objective:
It is very common for family members to become distressed when a terminally ill loved one
refuses food. The nurse needs to explore their fears and concerns and help them identify other
ways to express how they care.
• Before examining the infant of a Mexican American mother, the nurse compliments the
child's outfit. The mother becomes visibly distressed. Whatis the best next action for the nurse
, to take?
A. Ask the mother's permission to touch the child's hand
B. Interview the mother about the reason for bringing the child to the clinic
C. Reassure the mother that there is no reason for distress
D. Suggest postponing the examination until the mother calms down: Correctanswer: A. Ask
the mother's permission to touch the child's hand.
In Latin American culture, an illness called "mal de ojo" (evil eye) is believed to be caused
when a stranger or someone perceived as powerful admires or complimentsa child. The "illness,"
or "curse," is usually manifested by vomiting, fever, and crying.The mal de ojo curse can be
broken if the admirer touches the child while speakingto the child immediately afterward.
Mexican American mothers may worry when strangers compliment their babies without
touching them. To protect against mal deojo, the child may wear charms or beaded bracelets.
If the child is believed to be afflicted with mal de ojo, the parents may consult a traditional
healer, or curandero, who may perform rituals meant to cure the child ofthe curse.
Incorrect Answers
[Option B. Interview the mother about the reason for bringing the child to the clinic.] Asking
the mother about the reason for bringing the child to the clinic will not relieve the mother's
distress.
[Option C. Reassure the mother that there is no reason for distress.] This response is
nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness.
[Option D. Suggest postponing the examination until the mother calms down.] Postponing the
examination does not address the cause of the mother's distress.
Educational Objective:
Many Latin Americans beleive in "mal de ojo," or "evil eye," a cultural belief in
an illness thought to be manifested in children by vomiting, fever, and crying. It is
believed to be caused when a stranger admires a child without touching the child atthe same
time or immediately afterward.
