an lpn is taking care of an elderly client who experiences the effects of sundowners syndrome almost every evening which of these interventions imple
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. An LPN is taking care of an elderly client who experiences the effects of Sundowner's Syndrome almost every evening. Which of these interventions implemented by the nurse would be the most helpful?

Correct answer: A

Rationale: A nightlight will help reorient the client to his or her surroundings in the evening and nighttime hours. It is best not to challenge the reality of a client experiencing Sundowner's Syndrome, and sedatives may make the effects of the syndrome worse. Every effort should be made to keep the client's room calm, quiet, and peaceful, so noise should be kept to a minimum. Reminding the client that what they are experiencing is not real may cause distress and confusion, while turning on the TV or radio may add unnecessary stimulation instead of promoting a soothing environment.

2. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.

3. A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.

4. The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?

Correct answer: C

Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.

5. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

Similar Questions

When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?
A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?
While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?
During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?
A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?

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