NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
Question 2 of 5
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.
Question 3 of 5
The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
Question 4 of 5
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
Question 5 of 5
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.