the nurse overhears the patient care assistant speaking harshly to the client with dementia the charge nurse should

NCLEX-PN

Nclex 2024 Questions

1. What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?

A. Change the patient care assistant's assignment
B. Explore the interaction with the patient care assistant
C. Discuss the matter with the client's family
D. Initiate a group session with the patient care assistant

Correct answer: B

Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.

2. Who may legally give informed consent?

A. an 86-year-old male with advanced Alzheimer's disease
B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
D. a 6-month-old baby needing bowel surgery

Correct answer: C

Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer's disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.

3. When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:

A. that survivors have greater emotional turmoil and shock than when death is expected.
B. that survivors have less emotional turmoil and shock than when death is expected.
C. that survivors have the same emotional turmoil and shock as when death is expected.
D. that survivors have little emotional turmoil and shock because they were not there.

Correct answer: A

Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock. Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock. Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock. Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.

4. What is a common characteristic of individuals who become batterers?

A. Grew up in a loving, secure home.
B. Was an only child.
C. Was physically or psychologically abused.
D. Admits they have a problem with anger.

Correct answer: C

Rationale: The correct answer is 'Was physically or psychologically abused.' Research indicates that many individuals who become batterers have a history of being abused themselves. This cycle of abuse can influence their behavior as adults. Choice A is incorrect because growing up in a loving home does not necessarily prevent someone from becoming a batterer. Choice B is incorrect as being an only child is not a determining factor in becoming a batterer. Choice D is incorrect because while admitting to anger issues is a positive step, it is not a common characteristic of individuals who become batterers.

5. How can the nurse best communicate to a client that he or she has been listening?

A. restating the main feeling or thought the client has expressed
B. making a judgment about the client's problem
C. offering a leading question such as, 'And then what happened?'
D. saying, 'I understand what you're saying.'

Correct answer: A

Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.