Nursing Leadership and Management NCLEX Questions And Answers
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Course
PNR 415
Institution
PNR 415
A registered nurse reviews a plan of care developed by a nursing student for a client with depression and notes a nursing diagnosis of impaired nutrition: less than body requirements. The registered nurse asks the student to revise the plan if which incorrect intervention is documented?
a) offe...
Nursing Leadership and Management
NCLEX Questions And Answers
A registered nurse reviews a plan of care developed by a nursing student for a client with
depression and notes a nursing diagnosis of impaired nutrition: less than body requirements.
The registered nurse asks the student to revise the plan if which incorrect intervention is
documented?
a) offer small, high-calorie, high protein snacks frequently throughout the day and evening
b) offer high protein, high-calorie fluids frequently throughout the day and evening
c) remain with the client during meals
d) complete the food menu for the client during the depressed period - ANS D
- The client should be asked which foods or drinks she likes, and consultation with a dietitian
also may be done. The client is more likely to eat if the client has selected the foods and is
given foods that she likes. Options A, B, and C are appropriate interventions for the client with
depression with this nursing diagnosis.
A registered nurse reviews a plan of care developed by a nursing student for client with
paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse
asks the nursing student to revise the plan if which incorrect intervention is documented?
a) sit with the client and hold the client's hand
b) avoid a warm approach when working with the client
c) use simple and clear language when speaking to the client
d) diffuse angry and hostile verbal attacks with a nondefensive stand - ANS A
- When caring for a paranoid client, the nurse must avoid any physical contact and should not
touch the client. The nurse should ask the client's permission if touch is necessary because
touch may be interpreted as a physical or sexual assault. The nurse would use simple and clear
language when speaking to the client to prevent misinterpretation and to clarify the nurse's
intent and actions. A warm approach is avoided because it can be frightening to a person who
needs emotional distance. A matter-of-fact consistency is nonthreatening. Any anger and hostile
verbal attacks need to be diffused with a nondefensive stand. The anger that a paranoid client
expresses is often displaced, and when the staff becomes defensive, anger of both the client
and staff escalates. A nondefensive and nonjudgmental attitude provides an attitude in which
feelings can be explored more easily.
A registered nurse is discussing the characteristics of anorexia nervosa with a nursing student.
The registered nurse determines that the nursing student needs to further research this disorder
if the student states that which of the following is a characteristic of anorexia nervosa?
, a) personal relationships tend to become more superficial and distant
b) social contacts are avoided because of the fear of being invited to eat and being discovered
c) the client is being preoccupied with food and meal planning, especially for others
d) the client will usually keep her weight near normal - ANS D
- As anorexia nervosa develops, personal relationships tend to become more superficial and
distant. Social contacts are avoided because of the fear of being invited to eat and being
discovered. The client is preoccupied with food and meal planning (especially for others),
personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons are
likely to become very emaciated and will not maintain their near-normal body weight.
An experienced emergency department nurse observes a new nurse employed in the
emergency department obtain the equipment needed to draw a blood sample for a blood
alcohol level on a client. The experienced emergency department nurse intervenes if the new
nurse plans to use which item?
a) tourniquet
b) alcohol swabs
c) a blood-draw needle
d) a blood tube - ANS B
- Isopropyl alcohol or any antiseptic solution containing alcohol must not be used as a skin
preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the
blood alcohol level and render the test invalid. Option A, C and D identify items needed to obtain
the blood specimen.
A nurse administers digoxin (Lanoxin) 0.25 mg instead of the prescribed order of 0.125 mg. The
nurse discovers the error while charting the medication. The nurse completes an incident report
and notifies the physician of the incident. The nurse takes which additional action?
a) gives the client a copy of the incident report
b) makes a copy of the incident report and sends it to the physician's office
c) documents the incident in the client's record
d) places the incident report in the client's record - ANS C
- The incident report is confidential and privileged information. It should not be copied or placed
in the chart or have any reference made to it in the client's record. It is the physician's
responsibility to sign the incident report before it is sent to the risk-management department. A
copy should not be made or sent to the physician's office. The incident report is not a substitute
for a complete entry in the client's record concerning the incident. A copy of the incident report is
not given to the client; however, the client should be informed of the error, and this is usually
done by the client's physician.
A registered nurse is supervising a new nursing graduate who is performing an irrigation on an
assigned client with a buildup of cerumen in the left ear. Which of the following observations if
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