Saunders NCLEX PN NGN Newest Test Bank
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Client returns after 6 months after starting behavioral therapy.
Which statement by the parent indicates a need for further
therapy?
A) "My child will eat but only if I cook the same meal
everyday."
B) "My child will make only brief periods of eye contact with
the teacher."
C) "My child will occasionally play with other children at the
park."
D) "My child will squeeze a soft toy instead of banging the
head." - ANSWER-A
When evaluating the effectiveness of behavioral therapy the
nurse should recognize that narrowed, restricted interest indicate
a need for additional therapy.
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The nurse is monitoring a 12-month old diagnosed with
intussusception. Which findings should the nurse expect? SATA
A) Palpable olive shaped mass in epigastrium
B) Palpable sausage shaped mass in URQ
C) Projectile vomiting containing blood
D) Screaming and drawing the knees up to the chest
E) Stool mixed with blood and mucus - ANSWER-B, D, E
the triad of intussusception is intermittent severe crampy
abdominal pain; a palpable sausage shaped mass on the right
side of the abdomen and jelly stools.
Pyloric stenosis presents as frequent hunger, olive shaped mass
right of the umbilicus, and projectile vomiting without blood.
A client on hospice home care is taking sips of water, but
refusing food. Family members appear distressed and insists the
personal care worker force feed the client. What is the priority
nursing action?
A) explain to the family that is the normal physiological
response to dying
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B) explore the families, thoughts and concerns about the clients
refusal food
C) recommend a feeding tube
D) tell the family that force feeding the client could cause the
client to choke on the food - ANSWER-B
It's common for family members to become distressed when a
terminally ill loved one refuses food. The nurse should explore
their fears and concerns and help them identify other ways to
express how they care.
The nurse is performing rounding on clients in restraints. Which
situation would require immediate intervention by the nurse?
A) client in a belt restraint in the semi Fowler position
B) client in mitten restraints in the side lying position
C) client in soft wrist restraints in the supine position
D) client in vest restraint in the high Fowlers position -
ANSWER-C
Restrained clients are at risk for aspiration when supine. They
cannot safely swallow expel, secretions or emesis. They should
be placed in side lying, semi Fowler, or high fowler position.
The nurse is preparing to administer eardrops to an adult client.
It would require follow up if the nurse.
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A) instills the eardrops at room temp
B) instills the ear drops by placing the dropper into the ear canal
C) pulls the pinna of the clients ear up and back before
installation
D) place is a cotton ball loosely in the outer, most auditory canal
after installation - ANSWER-B
The nurse should hold the dropper 1/2 inch or 1 cm above the
ear canal to avoid damaging the ear with the dropper. Eardrops
should be warm, a cotton ball should be placed, pin a should be
pulled back
The nurse is preparing to irrigate the wound of a seven year old
client who sustained a laceration while on a playground. Which
of the following action should the nurse take? SATA
A) administer, he prescribed analgesic 30 minutes before
irrigating the
B) cleanse the wound from the most contaminated to the least
contaminated area
C) obtain a 10 mL syringe and a 27 gauge needle
D) review the clients vaccination record
E) use continuous pressure to flush the wound repeat until
drainage is clear - ANSWER-A, D, E