Nclex Questions Management of Care

Extract:

Question 1 of 5

When planning play activities for a hospitalized school-age child, a nurse uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing which developmental goal?

Correct Answer: C

Rationale: The correct answer is 'A sense of industry.' According to Erikson, the central task of the school-age years is the development of a sense of industry. During this stage, children engage in activities like schoolwork, crafts, chores, hobbies, and sports to develop a sense of competence and productivity. The development of trust is the primary task of infancy, autonomy is the task of toddlerhood, and initiative is the task of the preschool years.
Therefore, in this scenario, focusing on fostering a sense of industry aligns with the developmental goals of a school-age child.

Question 2 of 5

To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?

A. flexion, extension, hyperextension B. flexion, extension, abduction, adduction C. external rotation, internal rotation D. extension, flexion, inversion, eversion

Correct Answer: D

Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.

Question 3 of 5

When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:

A. Pregnancy tests are not reliable while taking the drug. B. She must use a reliable form of birth control. C. She should not take the Category X drug on days she has intercourse. D. She must follow up with an endocrinologist.

Correct Answer: B

Rationale: When a drug is categorized as Category X, it signifies that there are significant risks of fetal abnormalities if taken during pregnancy. For this reason, women of child-bearing age/capacity should use reliable forms of birth control to prevent pregnancy while on the medication. This ensures that the client avoids the potential harm to the fetus. Option A is incorrect because pregnancy tests are not unreliable due to the drug, but rather the risk is related to potential harm to the fetus. Option C is incorrect as avoiding the drug only on days of intercourse does not provide sufficient protection against pregnancy. Option D is incorrect as the need for an endocrinologist is not directly related to the use of Category X drugs.

Question 4 of 5

A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

A. Notify the physician. B. Clamp the chest tube. C. Replace the system. D. Document the finding

Correct Answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse.
Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

Question 5 of 5

When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

A. grief work facilitation B. vital signs monitoring C. medication administration: skin D. anxiety reduction

Correct Answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn.

Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature.

Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity.

Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

Nclex Questions Management of Care - Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN