NCSBN TEST BANK FOR THE NCLEX RN 2024/2025 VERIFIED QUESTIONS and Answers with Rationale BEST EXAM SOLUTION GRADED A+

What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives D) Clinical Pathway Protocols - C) Advance Directives It specifies client's wishes. You are the of a health care team that consists of one licensed practical nurse, one nursing assistant, a nursing student, and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The LPN D) The nursing assistant - A) Yourself While the nurse may delegate a bed bath for a stable patient, this care needs to be performed by an RN for a new admission. A mother brings her child to the clinic complaining. The nurse expects to find which of the following in the clinical history and physical assessment? A) Increased temperature and lethargy B) Rash and restless C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor - B) Rash and restless As the nurse takes a history of a 3-year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." - C) "Clothes are becoming tighter across her abdomen" One of the common signs is increase in abdominal girth, needing an additional assessment. A 16-year-old presents at the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate initial action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client - D) Assess and treat in the same manner as any adult client Minors may become known as "emancipated minor" through marriage, pregnancy, high school graduation, independent living, or service in the military (have the legal capacity of an adult). A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an UAP? A) Obtain a history of fluid loss B) Report output of less than 30ml/hr C) Monitor response to IV fluids D) Check skin turgor every 4 hours - B) Report output of less than 30ml/hr RN is responsible for all care-related decisions, only implementing tasks should be assigned because they don't require independent judgement. The nurse is assessing a 4 year old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox 6 months ago B) Exposure to strep throat in daycare last month C) Treatment for ear infection 2 months ago D) Episode of fungal skin infection last week - B) Exposure to strep throat in daycare last month A strong relationship between infection with Group A Strep and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, playmates recovering from strep throat would most likely mean that they had strep throat. Sometimes, such an infection has no clinical symptoms. When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the best action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior - A) Discuss the feeling of reluctance with an objective peer or supervisor The nurse can gain more objectivity through supervision and must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.