Client needs NCLEX questions and Answers with complete solutions

Client needs NCLEX questions and Answers with complete solutions A client diagnosed with a personality disorder will begin recreational therapy as a component of the treatment plan. The nurse provides information to the client regarding the therapy, knowing that this modality is helpful for clients who demonstrate which behavior? 1.Anger 2.Difficulty socializing 3.Violent tendencies toward others 4."Numbness" when experiencing intense feelings - ANS- ans: 2 2.Difficulty socializing Recreational therapy helps clients with personality disorders explore ways to enjoy themselves without the use of self-destructive behaviors, such as abusing alcohol or drugs. This modality is helpful to clients who have difficulty socializing because recreation strengthens social skills. Art therapy may be helpful for the client who is angry. The client who is exhibiting violent behavior may require medication therapy. Movement therapy may be helpful for clients who become "numb" when experiencing intense feelings. A client diagnosed with gastric cancer is being sent home from the hospital and will be receiving total parenteral nutrition (TPN). As part of the discharge teaching, the client and family members have been taught the aspects of home care for TPN. What comment by the client indicates a need for further teaching? 1."This therapy gives me needed calories." 2."I have to monitor my weight every day." 3."I need to document my fluid intake and output while I'm on this nutrition." 4."My doctor will check my calcium level because it can drop too low while I am on this nutrition." - ANS- ans: 4 4."My doctor will check my calcium level because it can drop too low while I am on this nutrition." Calcium imbalances, particularly hypercalcemia, are associated with TPN. A client has a newly fractured fibula that was plaster casted in the emergency department. Because the client will need to use crutches, which crutch-walking gait should the nurse teach the client before discharge? 1) two point gate 2) three point gate 3)swing through gate 4)four point alternate gait - ANS- 2) three point gate A client has cirrhosis complicated by ascites. Which expected but adverse laboratory result should the nurse monitor for? 1.High urine sodium 2.Low serum albumin 3.High serum calcium 4.Low urine specific gravity - ANS- ans: 2 2.Low serum albumin The client with ascites as a complication of cirrhosis loses plasma proteins into the ascitic fluid. Over time, this causes the client's serum albumin and total protein levels to decrease. This problem also is aggravated by decreased protein synthesis by the cirrhotic liver A client has decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow. The nurse determines that the client's condition is improved if which data are obtained on assessment of the client? 1) Dyspnea while ambulating to the bathroom is reduced. 2) Presence of fine bibasilar lung crackles on auscultation is noted. 3) Oxygen saturation is increased from 82% to 88% by pulse oximeter. 4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg. - ANS- ans: 4 4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg. Signs and symptoms that correlate with decreased pulmonary perfusion include dyspnea and hypoxia, making options 1 and 3 incorrect. Crackles indicate fluid in the alveoli, which impairs gas exchange at the alveolar level, making option 2 incorrect. A client is suspected of having pulmonary tuberculosis (TB). The nurse assesses the client for which manifestations of this communicable disease? Select all that apply. 1) Hematuria 2) Chest pain 3) Hemoptysis 4) Night sweats 5) High fever at night - ANS- ans: 2, 3, 4 2) Chest pain 3) Hemoptysis 4) Night sweats The client with pulmonary TB generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles. A client received a dose of regular insulin (Humulin R) this morning at 7:00 a.m. At what approximate time would the nurse likely anticipate the potential for a hypoglycemic reaction to occur? 1. 8:00 a.m. 2. 10:00 a.m. 3. 12:00 p.m. 4. 2:00 p.m. - ANS- ans: 2 2. 10:00 a.m. Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. Hypoglycemic reactions are most likely to occur during the peak action of insulin. A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom? 1.Diarrhea 2.Bleeding 3.Infection 4.Epigastric pain - ANS- ans: 4 4.Epigastric pain The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol is administered to prevent this occurrence. A client seen in the health care clinic is scheduled for several diagnostic procedures. An abdominal aorta sonogram, a barium enema, an upper gastrointestinal (GI) series, and a small bowel series are prescribed. What should the nurse schedule first? 1.Barium enema 2.Upper GI series 3.Small bowel series 4.Abdominal aorta sonogram - ANS- ans: 4 4.Abdominal aorta sonogram The abdominal aorta sonogram should be performed before intestinal barium tests or after the barium is cleared from the system. The barium will obstruct the view when the abdominal aorta sonogram is obtained. The tests identified in the other procedures use barium for the visualization of these organs during diagnostic study. A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide? 1.Avoid prolonged exposure to the sun. 2.Adhere to a strict tyramine-restricted diet. 3.Recognize the signs and symptoms of a relapse of depression. 4.Have therapeutic blood levels drawn because the medication has a narrow therapeutic range. - ANS- ans: 1 1.Avoid prolonged exposure to the sun. photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs). Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels. A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family? 1) Inform the friend to directly contact the family and offer assistance to them. 2) Request that the friend come to the client's home during the next home health visit. 3) Report the friend's call to the nurse manager for referral to the client's social worker. 4) Assure the friend that there is no need for assistance since the nurse is visiting daily. - ANS- ans: 1