Nclex Questions Management of Care - Nurselytic

Correct Answer: A

Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing.
Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling.
Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing.
Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.

Correct Answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn.

Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature.

Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity.

Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

Correct Answer: B

Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer.
Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge.
Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively.
Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.

Correct Answer: A

Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing.
Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling.
Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing.
Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.

Correct Answer: A

Rationale: In an emergency situation, assessing the client's ability to speak is crucial in determining airway obstruction. If a client can speak, it indicates that the airway is patent and not completely obstructed.

Choices B and C, assessing the ability to hear and oxygen saturation, are not directly indicative of an airway obstruction.
Choice D, adventitious breath sounds, may be present in conditions like asthma or pneumonia but are not specific to determining an airway obstruction.