NCLEX-RN
Caring for a Patient Questions
Question 1 of 5
The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
Correct Answer: B
Rationale: The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and the client's thinking are unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. The client would not be placed in a private room because this is an unsafe action that may intensify the client's feelings of worthlessness. Distance of 18 inches or less between two individuals constitutes intimate space. The invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness. Placing the client in charge of the morning chess tournament is a premature intervention that can overwhelm the client and cause the client to fail; this can reinforce the client's feelings of worthlessness.
Question 2 of 5
A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?
Correct Answer: A
Rationale: Nurses should be able to explore measures that assist the family with creating memories of the infant so that the existence of the child is confirmed, and the parents can complete the grieving process. The correct option identifies this measure and also demonstrates a caring and empathetic client-focused response while providing the family with the option to express their needs. Option 2 devalues the parents' feelings and is inappropriate. Option 3 is inappropriate and reflects a lack of knowledge on the nurse's part. Option 4 appears that the nurse is uncaring.
Question 3 of 5
A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?
Correct Answer: A
Rationale: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
Question 4 of 5
Shortly after a client dies, the nurse asks the family about funeral arrangements. When the family refuses to discuss the issue, which intervention by the nurse is appropriate for their stage of grief?
Correct Answer: D
Rationale: The family is exhibiting the first stage of grief: denial. By asking the family if they would like time alone with the client, the nurse supports the family's feelings and allows the family to process the death. Option 1 is a suitable intervention for the acceptance or reorganization and restitution stage of grief. Eliminate options 2 and 3 because they are not appropriate at this time since the family has indicated their desire not to discuss funeral arrangements.
Question 5 of 5
A client and her infant have been diagnosed as being positive for human immunodeficiency virus (HIV). When the mother is observed crying, the nurse determines that which intervention will meet the client's initial needs?
Correct Answer: B
Rationale: This client has just received devastating news and needs to have someone present with her as she begins to cope with this issue. The nurse needs to sit and actively listen while the mother talks and cries. Examining the mother and describing the progression and treatment of HIV is not appropriate for this stage of coping. Calling an HIV counselor may be helpful, but it is not what the client needs initially.