Next Generation Nclex Questions Overview 3.0 ATI Quizlet - Nurselytic

Correct Answer: C

Rationale:
To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure.
Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues.
Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care.
Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

Correct Answer: A

Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.

Correct Answer: C

Rationale: Termination in the nurse-client relationship should first be addressed in the orientation phase. This is because the client has a right to know the parameters of the relationship from the beginning. During the orientation phase, it is important to discuss if the relationship is time-limited, inform the client about the number of sessions, or explain that it is open-ended with the termination date to be negotiated later. Addressing termination in the orientation phase helps establish transparency and clear communication.

Choices A, B, and D are incorrect because termination discussions should ideally start at the beginning of the relationship to set appropriate expectations.

Correct Answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, the best nursing intervention is to identify the child's home bedtime rituals and follow them. Preschool-age children often have specific bedtime routines that provide comfort and promote sleep. This familiarity can help create a sense of security in an unfamiliar hospital environment.
Choice A, turning off the room light and closing the door, may increase the child's fear of the dark and being alone.
Choice B, engaging the child in calming activities before bedtime, is a better choice than tiring them with play exercises.
Choice D, encouraging relaxation techniques like deep breathing exercises, although helpful, may not be as effective as following the child's familiar bedtime routines.

Correct Answer: D

Rationale: Huntington's chorea is characterized by writhing, twisting movements of the face and limbs, known as chorea. This disorder is caused by a genetic mutation affecting specific brain cells. Epilepsy presents with seizures, Parkinson's with tremors and rigidity, and multiple sclerosis with central nervous system issues. The specific description of writhing and twisting movements aligns with Huntington's chorea, making it the correct answer.

Choices A, B, and C are incorrect as they describe different neurological disorders with distinct symptoms that do not match the writhing, twisting movements characteristic of Huntington's chorea.