NCLEX-RN
Caring for a Patient Questions
Extract:
Question 1 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 2 of 5
When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?
Correct Answer: D
Rationale: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.
Question 3 of 5
The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with their concerns?
Correct Answer: A
Rationale: Families often need assistance to cope with the sudden severe illness of a loved one. The nurse should explain all equipment, treatments, and procedures, and he or she should supplement or reinforce the information given by the primary health care provider. Displaying grief is a normal process and should not be discouraged. The family should be encouraged to touch and speak to the client and become involved in the client's care in some way if they are comfortable with doing so. The nurse should allow the family to stay with the client whenever possible. This is important for both the client and the family.
Question 4 of 5
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, 'If this is a stroke, it's the kiss of death.' What initial response should the nurse make?
Correct Answer: B
Rationale: Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.
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.