Questions 17

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Health Promotion and Maintenance Practice Questions Questions

Extract:


Question 1 of 5

The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?

Correct Answer: A

Rationale: Diabetic ketoacidosis (DK
A) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.

Question 2 of 5

A first-time parent is discussing developmental milestones with a nurse. The nurse tells the client she can reasonably expect her child to achieve which of the following by the time the child is 2 years old?

Correct Answer: D

Rationale: By age 2, children typically say several single words. Hand dominance emerges later, clinging is earlier, and walking is independent by 2.

Question 3 of 5

The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?

Correct Answer: D

Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.

Question 4 of 5

The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?

Correct Answer: A

Rationale: Diabetic ketoacidosis (DK
A) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.

Question 5 of 5

The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?

Correct Answer: B

Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.

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