PrepU Nclex questions L4MS

1. An elderly Cantonese-speaking client has been admitted to the emergency department after suffering a fall and suspected hip fracture in her home. Emergency medical services personnel have reported to the nurse that the client speaks no English. Who is the best person to perform translation services? - A hospital translator 2. A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents? The correct procedure for auscultating the client’s abdomen for bowel sounds is to: - 3. . A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? 4. A client is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity. The client states, "I am the savior of the city." The family states that the client has hardly slept or eaten for days. Which client need is a priority in the nurse's plan of care? 5. A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse? 6. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? 7. Adolescents and adults who were sexually abused as children commonly mutilate themselves. The nurse interprets this behavior as: 8. A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to 9. A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? 10. A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? 11. A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? ..................................................continued....................................................