NCLEX-RN
Caring for a Patient Questions
Extract:
Question 1 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 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
When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?
Correct Answer: D
Rationale: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.
Question 4 of 5
A client diagnosed with incurable cancer has a life expectancy of a few weeks. Which response indicates that the client's partner is reacting with an expected coping response?
Correct Answer: B
Rationale: Anger is a normal stage of the grieving process and is an expected coping response when facing the imminent loss of a loved one. Expressing anger toward a spiritual entity, such as God, is a common way for individuals to process their grief. Refusing to visit the client indicates avoidance or denial, which may not be constructive. Not allowing the death to occur at home or sending children to live with relatives may reflect practical decisions but do not directly indicate an expected emotional coping response related to grief.
Question 5 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.