NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
Correct Answer: D
Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness.
Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage.
Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage.
Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.
Question 2 of 5
A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
Correct Answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test.
Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
Question 3 of 5
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.
Question 4 of 5
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Question 5 of 5
A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
Correct Answer: D
Rationale: The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders.
Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.