During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?

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Critical Care Nursing NCLEX Questions Questions

Question 1 of 5

During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?

Correct Answer: D

Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions. A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions. B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario. C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.

Question 2 of 5

The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

Correct Answer: A

Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.

Question 3 of 5

A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?

Correct Answer: D

Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes. Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care. Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care. Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality

Question 4 of 5

A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?

Correct Answer: B

Rationale: The correct answer is B: Appropriate staffing. In this scenario, the nurse is conflicted because she is the only nurse available to tend to both critical patients. Appropriate staffing ensures that there are enough healthcare professionals to provide timely and effective care to patients in need. In this situation, the lack of adequate staffing is evident as the nurse is overwhelmed and unable to give proper attention to both patients simultaneously. Effective decision making (choice A) can be hindered by inadequate staffing but is not the primary issue here. Authentic leadership (choice C) and meaningful recognition (choice D) are important components of a healthy work environment but are not directly related to the lack of staffing in this scenario.

Question 5 of 5

The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?

Correct Answer: B

Rationale: The correct answer is B because certification validates nurses' expert knowledge and practice. This is important as it ensures that nurses have the necessary skills and competence to provide high-quality care in critical care settings. Certification is voluntary and not mandated by government regulations (Choice C). It goes beyond demonstrating basic knowledge (Choice D) by confirming specialized expertise. While certification may garner positive publicity (Choice A), the primary benefit is the validation of advanced skills and knowledge.

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