Nclex Exam Cram Practice Questions - Nurselytic

Correct Answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

Correct Answer: D

Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep.

Choices A, B, and C are incorrect.
Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause.
Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues.
Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.

Correct Answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice
B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice
C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice
D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

Correct Answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate.
Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.

Correct Answer: D

Rationale: The correct answer is '
To be aware of the role of the licensed nurse.' Nurse practice acts outline the scope of practice for nurses, defining what constitutes nursing practice and the role of licensed nurses.
Choice A is incorrect because hospital and long-term care facility policies are institution-specific and not typically covered in the nurse practice act.
Choice B is incorrect as the scope of practice for nurses is a part of the nurse practice act, but it's not the sole purpose for a nurse to refer to it.
Choice C is incorrect as health care policies in a state are governed by other legislative acts, not the nurse practice act.