NCSBN NCLEX Review Questions and Answers with complete solution

A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? 1. "I need you to go to the waiting area. You can come back when you're more in control." 2. "I'm going to give you a few minutes alone so you can calm down." 3 "I can't think when you are yelling at me. Talk to me in a normal voice." 4. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Correct Answer- "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help. The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings does the nurse recognize as being reportable to the public health department? Positive eye discharge confirming conjunctivitis Clinical findings of impetigo Skin scraping confirming the presence of ringworm Positive stool culture for shigella Correct Answer- Positive stool culture for shigella The Centers for Disease Control and Prevention (CDC) have a list of notifiable infectious diseases that is updated yearly. Shigellosis is the only reportable infection of those listed. Shigella are bacteria that can infect the digestive tract and cause (painful) diarrhea, cramping, vomiting, nausea; in severe cases it can cause seizures and kidney failure. Ringworm is a contagious fungal infection. Impetigo is a contagious, superficial bacterial skin infection. Conjunctivitis has many causes and is usually diagnosed from signs and symptoms and patient history. Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first? The person with multiple wounds and an open fracture The person with hypotension and a sucking chest wound The person with head trauma requiring mechanical ventilation The person with an undisplaced fracture of the radius Correct Answer- Typically, the tab colors used in triage are black, yellow, green and red. Red-tagged clients have immediate threats to life and require care right away; this would be the survivor with hypotension and a sucking chest wound. Yellow-tagged clients have major injuries that need treatment within 30 minutes to two hours (the client with the open fracture), and green-tagged client have injuries that can be delayed more than two hours (the closed fracture). Black-tagged clients are treated last during a mass casualty situation because there is little chance for survival.