NCLEX-RN
Caring for a Patient Questions
Extract:
Question 1 of 5
The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time?
Correct Answer: B
Rationale: If a client begins to cry, the nurse should stay with the client and let the client know that it is all right to cry. The nurse should ask the client what the client is thinking or feeling at the time. By continuing the bath or by leaving the client, the nurse appears to be ignoring the client's feelings. Crying alone is not necessarily an indication of depression, and calling the primary health care provider is a premature action.
Question 2 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 3 of 5
The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
Correct Answer: B
Rationale: The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and the client's thinking are unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. The client would not be placed in a private room because this is an unsafe action that may intensify the client's feelings of worthlessness. Distance of 18 inches or less between two individuals constitutes intimate space. The invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness. Placing the client in charge of the morning chess tournament is a premature intervention that can overwhelm the client and cause the client to fail; this can reinforce the client's feelings of worthlessness.
Question 4 of 5
A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The client is very upset and states, 'This is the doctor's fault! I did everything that I was told to do!' When considering the grieving process, how should the nurse respond to the client's statement?
Correct Answer: C
Rationale: Anger is a stage in the grieving process and an expected response to impending loss. Usually a client directs the anger toward himself or herself, God or another spiritual being, or the caregivers; thus far the client's behavior demonstrates effective coping. Notifying the risk management department is premature, especially because the client has said nothing about legal action. Analyzing alternative treatment options and previous health care providers is likely to interfere with effective coping, and it can delay lifesaving treatment.
Question 5 of 5
The nurse cared for a client who died a few minutes ago. Which event supports the nurse's belief that the client died with dignity?
Correct Answer: A
Rationale: The family response is an external perception, and it is extremely important. Families derive a great deal of comfort from knowing that their loved one received the best care possible. The correct option provides external validation that the client received comprehensive, quality care. Option 2 focuses on the feelings of the nurse, who may be expressing his or her own anxiety. Option 3 focuses on the provider's prescriptions rather than client care. Option 4 reflects on only one aspect of the care of a dying client.