Safe and Effective Care Environment Nclex PN Questions - Nurselytic

Correct Answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety.

Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls.
Therefore, these options would suggest an increased risk for falls.

Correct Answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception.

Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa.
Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception.
Choice B involves assertiveness with family, which is more related to family dynamics.
Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

Correct Answer: A

Rationale: Common problems for supervisors include micromanaging staff members, wanting to control the style in which a staff member performs a task, and not delegating tasks effectively. These behaviors can hinder team building and overall effectiveness. Facilitating the development of staff members, on the other hand, is a positive attribute for a supervisor as it helps in nurturing the skills and growth of the team members.
Therefore, the correct answer is 'the supervisor facilitates development of staff members' as this is not a common problem but a desirable quality in a supervisor.

Correct Answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection.
Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration.
Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection.
Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

Correct Answer: C

Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.