NCLEX-RN
Caring for a Patient Questions
Extract:
Question 1 of 5
The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse's initial action?
Correct Answer: C
Rationale: The nurse's initial intervention is to encourage the client to express feelings, which is facilitated by establishing a nurse-client relationship that is based upon respect. The correct option validates the perception that the client is depressed. This action also allows the nurse to assess the situation. Options 1, 2, and 4 address interventions before assessing the situation and identifying the client's actual needs.
Question 2 of 5
The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse's initial action?
Correct Answer: C
Rationale: The nurse's initial intervention is to encourage the client to express feelings, which is facilitated by establishing a nurse-client relationship that is based upon respect. The correct option validates the perception that the client is depressed. This action also allows the nurse to assess the situation. Options 1, 2, and 4 address interventions before assessing the situation and identifying the client's actual needs.
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
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, 'If this is a stroke, it's the kiss of death.' What initial response should the nurse make?
Correct Answer: B
Rationale: Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.
Question 5 of 5
A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?
Correct Answer: A
Rationale: Nurses should be able to explore measures that assist the family with creating memories of the infant so that the existence of the child is confirmed, and the parents can complete the grieving process. The correct option identifies this measure and also demonstrates a caring and empathetic client-focused response while providing the family with the option to express their needs. Option 2 devalues the parents' feelings and is inappropriate. Option 3 is inappropriate and reflects a lack of knowledge on the nurse's part. Option 4 appears that the nurse is uncaring.