Basic Care and Comfort NCLEX

Extract:

Question 1 of 5

A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

Correct Answer: B

Rationale:
Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.

Question 2 of 5

Perineal care to a female client by the nurse can be performed:

A. Without gloves, pouring water from a sterile bottle B. Without gloves, having the client perform all care C. With gloves, washing the perineal area from front to back D. With gloves, washing the perineal area from back to front

Correct Answer: C

Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.

Question 3 of 5

Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m. B. taking a cool shower and drinking a hot cup of tea C. watching TV nightly until midnight D. getting a back rub and drinking a glass of warm milk

Correct Answer: D

Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.

Question 4 of 5

The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach?

A. a high-protein meal B. a high-fat meal C. a large meal regardless of nutrient content D. a high-carbohydrate meal

Correct Answer: D

Rationale: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.

Question 5 of 5

The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.

A. Ask the client's permission to open containers and cut up meats on the food tray. B. Obtain special easy-to-hold, built-up silverware for the client to use when eating. C. Observe the client, but avoid providing assistance even if the client is frustrated. D. Help feed the client if the client is eating too slowly so food does not get too cold. E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.

Correct Answer: A,B,E

Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.

Basic Care and Comfort NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN