NCLEX-RN : Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #121 : Ethics, Processing, And Care

Prolonged alcohol abuse can result in a severe deficiency in what vitamin?

Possible Answers:

Vitamin C

Folate

Thiamine (B1)

Niacin (B3)

Correct answer:

Thiamine (B1)

Explanation:

Prolonged alcohol abuse can result in a severe deficiency in thiamine, or vitamin B1 by reducing dietary thiamine intake, impairing gastrointestinal absorption of thiamine, and causing impaired thiamine utilization in cells. Note that individuals who partake in prolonged alcohol abuse may have various other dietary deficiencies.

Example Question #121 : Ethics, Processing, And Care

Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal?

Possible Answers:

Bradycardia

Delirium tremens

Tachycardia

Agitation

Correct answer:

Delirium tremens

Explanation:

Delirium tremens (DT) is a rapid onset of confusion seen during alcohol withdrawal. The symptoms of DT include altered mental status, autonomic instability, and even seizures. DT is also characterized by hallucinations such as the sensation of something "crawling" on the patient. DT is the most severe consequence of withdrawal and can be fatal if untreated.

Example Question #1 : Nurse Patient Relationship

The client in the termination phase of the nurse-client relationship is being very confrontational. How should the nurse interpret this behavior?
Possible Answers:
This behavior is common for a client in the termination phase
The treatment should revisit the working phase
The nurse has done something to offend the client
The patient should be admitted to the hospital
Correct answer: This behavior is common for a client in the termination phase
Explanation: Confrontational behavior is very common for a client in the termination phase. The nurse should not assume that she offended the client, and further action in terms of therapy should not be addressed until completing the termination phase.

Example Question #24 : General Care

The nurse is in the orientation phase of the nurse-client relationship where the client has been sexually assaulted. During this phase, the nurse should:
Possible Answers:
Actively listen to the client express his thoughts and feelings
Explore personal ideas, stereotypes, and biases that my affect the nurse-client relationship
Establish acceptance, trust, and boundaries
Identify themes of patterns of patient behavior and possible coping mechanisms
Correct answer: Establish acceptance, trust, and boundaries
Explanation: During the orientation phase the nurse should establish acceptance, trust, and boundaries with the client, which will be built upon in later phases.

Example Question #2 : Nurse Patient Relationship

Acceptance, trust and boundaries are established during which phase of the therapeutic nurse-client relationship?
Possible Answers:
Working
Preinteraction
Termination
Orientation
Correct answer: Orientation
Explanation: Acceptance, trust, and boundaries are established in the orientation phase of therapy.

Example Question #1 : Mental And Physical Disabilities

Identify the disorder that presents the following signs and symptoms: numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause.

Possible Answers:

Schizophrenia

Stiff person syndrome

Conversion disorder

Bipolar disorder

Correct answer:

Conversion disorder

Explanation:

Conversion disorder is typified by numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause. Schizophrenia, bipolar disorder, and stiff person syndrome all have medically identifiable causes. 

Example Question #124 : Ethics, Processing, And Care

What is the best approach towards dealing with a delirious patient?

Possible Answers:

Frequent 4-point restraints

Frequent sedation with antipsychotics

Frequent reorientation to time, place, and name.

Frequent sedation with benzodiazepenes

Correct answer:

Frequent reorientation to time, place, and name.

Explanation:

Delirium is an organic dysfunction of the brain usually seen in sick patients post-op. These patients need frequent reorientation to name, time, and place until the delirium resolves. Agitation, confusion, and difficult to control behavior is typically controlled with antipsychotics, however, they are not first line treatment. Restraints should be avoided at all costs.

Example Question #71 : Care

A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Possible Answers:
Tell the client to call back if the condition worsens
Instruct the client to keep the arm elevated until swelling goes away
Advise the client to bring her daughter to the emergency room
Ask the client if her daughter has ever been stung by a bee in the past
Correct answer: Tell the client to call back if the condition worsens
Explanation: The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.

Example Question #2 : Prevention And Risk Management

The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?

Possible Answers:

Frequently turn and reposition patient while also providing skin care

Teach client the importance of coughing and deep breathing

Providing a well-balanced diet

Orient client frequently

Use compression stockings or TED hose

Correct answer:

Frequently turn and reposition patient while also providing skin care

Explanation:

There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.

Example Question #131 : Procedures And Care

The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should __________.

Possible Answers:

wait until the patient care is complete and replace the mask

exchange the mask for a new mask immediately

dry the mask with the in-room hairdryer

place a new mask over the old mask

wipe with mask with a clean towel

Correct answer:

exchange the mask for a new mask immediately

Explanation:

Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately. 

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