the nurse is preparing an older client for discharge which method is best for the nurse to use when evaluating the clients ability to perform a dress the nurse is preparing an older client for discharge which method is best for the nurse to use when evaluating the clients ability to perform a dress
Logo

Nursing Elites

NCLEX NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

Correct answer: Observe the client change the dressing unassisted.

Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.

2. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

Correct answer: The patient used IV drugs about 20 years ago

Rationale: The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.

3. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?

Correct answer: B: A bruit near the epigastric area

Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.

4. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:

Correct answer: Radiating pain

Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.

5. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is:

Correct answer: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. It is performed during a cardiac catheterization to improve coronary artery blood flow in a diseased artery. Surgical repair of a diseased coronary artery is typically done through procedures like aorto-coronary bypass graft (ACBG) rather than PTCA. Placement of an automatic internal cardiac defibrillator (AICD) is a different procedure used for managing cardiac arrhythmias. Non-invasive radiographic examination of the heart refers to procedures like echocardiography or cardiac MRI, not PTCA.

Similar Questions

Which oxygen delivery system would provide the highest concentrations of oxygen to the client?
In which of these patients would rectal temperatures be measured?
In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?
During the first meeting of a therapy group, members exhibit frequent periods of silence, tense laughter, and nervous movements. Which conclusion would the nurse make?
Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99