NUR-113-Unit 4 NCLEX Style Questions W/
Rationales Exam With Correct Answers
The nurse is caring for a patient who is experiencing an exacerbation of multiple
sclerosis. Her husband confides that the stress of caring for her, in addition to
their small children, has caused him to start smoking again after having quit
many years ago.
The nurse's understanding of which information can assist the nurse in
improving the husband's coping skills? - ANSWER The cost of cigarette smoking
can result in a serious financial burden for the family.
The patient's recovery will be impeded by the stress of discovering that her
husband has started smoking.
Smoking will most likely help the patient's husband to deal with her illness in the
short term.
*Ineffective coping can lead to unhealthy choices and increase the risk of
premature mortality in caregivers.
The nurse preceptor is orienting a new nurse to the unit. The preceptor explains
the concept of family-centered care to the new nurse.
Which action by the new nurse demonstrates an understanding of the
integration of family-centered care? - ANSWER *The nurse takes the help of an
interpreter when providing teaching to the non-English-speaking parents of an
infant.
The nurse consults with the dietary department to provide education for the
adolescent newly diagnosed with diabetes.
The nurse utilizes the five rights of medication administration prior to
administering a medication to a child.
The nurse utilizes patient rounding at the change of shift to introduce the nurse
on the oncoming shift to the adolescent patient.
Rational: The partnership between nurses and families is known as family-
centered care. For many families, providing family-centered care also means
providing culturally competent care. The nurse taking the help of an interpreter
when providing teaching to the non-English-speaking parents of an infant
demonstrates an understanding of family-centered care.
,The nurse is caring for a patient diagnosed with chronic alcoholism. The nurse
attends the care conferences with the patient and family to gain insight into the
familial relationships.
Which tool should the nurse utilize to help evaluate the familial relationships and
patterns of chronic conditions? - ANSWER Family APGAR
Friedman family assessment tool
*Family genogram
Family ecomap
The nurse learns that a patient with school-age children is also her mother's
caregiver. The patient states, "I can no longer meet everyone's needs anymore."
Which concern should the nurse identify for this patient? - ANSWER
*Compromised family coping
Readjustment of marital relationship
Sandwich generation syndrome
Adjusting to outside influences
Rational: Adults in this group are known as "The Sandwich Generation," which is
not a nursing diagnosis.
The nurse is providing family-centered care for a patient with severe mental
illness. The patient is currently hospitalized for displaying inappropriate sexual
behavior, causing damage to the property of others, and aggressively arguing
with family members.
Based on the patient's behavior, which type of distress is the family
experiencing? - ANSWER Social stigma of mental illness
Caregiver burnout
*Objective family burden
Subjective family burden
The nurse is conducting a program on summer safety for families of a residential
community.
Which participant statement indicates that the teaching has been effective? -
ANSWER *"Children should learn how to swim."
"Air-filled floats should be kept around the pool."
, "A bump on the head is nothing to be concerned about."
"Head gear while playing touch football is not necessary."
Rational: To support water safety, all children should learn how to swim through
formal training. A bump on the head could lead to a concussion. The use of foam
or air-filled floatation devices as replacements for life jackets should be avoided.
Head gear should be worn while participating in contact sports to prevent head
injuries.
A pregnant patient informs the nurse about her plans to rearrange their
bedroom to make room for the baby.
Which safety teaching should the nurse provide? - ANSWER *"Avoid moving
heavy objects."
"Drink enough fluids."
"Take prenatal vitamins."
"Eat a proper diet."
Rational: The nurse should remind the patient to avoid activities that present the
risk for injury, such as moving heavy objects. While the mother needs to drink
fluids, eat well, and take prenatal vitamins, the nurse does not need to address
these concerns directly in terms of injury prevention.
The nurse caring for a patient who has a chronic staph infection on their legs
performs a home environmental assessment.
Which finding may be the cause of the infection? - ANSWER *Old upholstery with
years of accumulated dirt
Throw rugs in the walkways
Poor lighting in the kitchen
Empty cupboards in the kitchen
Rational: The purpose of a home health environment assessment is to assess
safety risks for infection, malnutrition, and injury. Dirty upholstery is a risk for
continued skin infections, particularly if the person's infected leg is often in
contact with the furniture. Poor lighting and throw rugs present risks for falls,
but not for staph infection. The empty cupboards suggest that the resident is
malnourished.
Rationales Exam With Correct Answers
The nurse is caring for a patient who is experiencing an exacerbation of multiple
sclerosis. Her husband confides that the stress of caring for her, in addition to
their small children, has caused him to start smoking again after having quit
many years ago.
The nurse's understanding of which information can assist the nurse in
improving the husband's coping skills? - ANSWER The cost of cigarette smoking
can result in a serious financial burden for the family.
The patient's recovery will be impeded by the stress of discovering that her
husband has started smoking.
Smoking will most likely help the patient's husband to deal with her illness in the
short term.
*Ineffective coping can lead to unhealthy choices and increase the risk of
premature mortality in caregivers.
The nurse preceptor is orienting a new nurse to the unit. The preceptor explains
the concept of family-centered care to the new nurse.
Which action by the new nurse demonstrates an understanding of the
integration of family-centered care? - ANSWER *The nurse takes the help of an
interpreter when providing teaching to the non-English-speaking parents of an
infant.
The nurse consults with the dietary department to provide education for the
adolescent newly diagnosed with diabetes.
The nurse utilizes the five rights of medication administration prior to
administering a medication to a child.
The nurse utilizes patient rounding at the change of shift to introduce the nurse
on the oncoming shift to the adolescent patient.
Rational: The partnership between nurses and families is known as family-
centered care. For many families, providing family-centered care also means
providing culturally competent care. The nurse taking the help of an interpreter
when providing teaching to the non-English-speaking parents of an infant
demonstrates an understanding of family-centered care.
,The nurse is caring for a patient diagnosed with chronic alcoholism. The nurse
attends the care conferences with the patient and family to gain insight into the
familial relationships.
Which tool should the nurse utilize to help evaluate the familial relationships and
patterns of chronic conditions? - ANSWER Family APGAR
Friedman family assessment tool
*Family genogram
Family ecomap
The nurse learns that a patient with school-age children is also her mother's
caregiver. The patient states, "I can no longer meet everyone's needs anymore."
Which concern should the nurse identify for this patient? - ANSWER
*Compromised family coping
Readjustment of marital relationship
Sandwich generation syndrome
Adjusting to outside influences
Rational: Adults in this group are known as "The Sandwich Generation," which is
not a nursing diagnosis.
The nurse is providing family-centered care for a patient with severe mental
illness. The patient is currently hospitalized for displaying inappropriate sexual
behavior, causing damage to the property of others, and aggressively arguing
with family members.
Based on the patient's behavior, which type of distress is the family
experiencing? - ANSWER Social stigma of mental illness
Caregiver burnout
*Objective family burden
Subjective family burden
The nurse is conducting a program on summer safety for families of a residential
community.
Which participant statement indicates that the teaching has been effective? -
ANSWER *"Children should learn how to swim."
"Air-filled floats should be kept around the pool."
, "A bump on the head is nothing to be concerned about."
"Head gear while playing touch football is not necessary."
Rational: To support water safety, all children should learn how to swim through
formal training. A bump on the head could lead to a concussion. The use of foam
or air-filled floatation devices as replacements for life jackets should be avoided.
Head gear should be worn while participating in contact sports to prevent head
injuries.
A pregnant patient informs the nurse about her plans to rearrange their
bedroom to make room for the baby.
Which safety teaching should the nurse provide? - ANSWER *"Avoid moving
heavy objects."
"Drink enough fluids."
"Take prenatal vitamins."
"Eat a proper diet."
Rational: The nurse should remind the patient to avoid activities that present the
risk for injury, such as moving heavy objects. While the mother needs to drink
fluids, eat well, and take prenatal vitamins, the nurse does not need to address
these concerns directly in terms of injury prevention.
The nurse caring for a patient who has a chronic staph infection on their legs
performs a home environmental assessment.
Which finding may be the cause of the infection? - ANSWER *Old upholstery with
years of accumulated dirt
Throw rugs in the walkways
Poor lighting in the kitchen
Empty cupboards in the kitchen
Rational: The purpose of a home health environment assessment is to assess
safety risks for infection, malnutrition, and injury. Dirty upholstery is a risk for
continued skin infections, particularly if the person's infected leg is often in
contact with the furniture. Poor lighting and throw rugs present risks for falls,
but not for staph infection. The empty cupboards suggest that the resident is
malnourished.
