which of the following is an example of restorative care

NCLEX-RN

NCLEX RN Exam Review Answers

1. Which of the following is an example of restorative care?

A. A nurse teaches a new mother how to breastfeed her infant
B. A nurse helps a client with developing a bladder-retraining program
C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.

2. A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A. G4 T1 P0 A1 L2
B. G3 T1 P0 A1 L2
C. G3 T0 P1 A1 L2
D. G4 T0 P1 A1 L2

Correct answer: D

Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history. G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies. T1: She has had one pregnancy that resulted in the birth of her twins at term. P0: She has not had any preterm births. A1: She had one miscarriage at 12 weeks gestation. L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.

3. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

A. Place the client in the Trendelenburg position
B. Contact the physician for an order for antibiotics
C. Administer oxygen therapy
D. Decrease his IV rate

Correct answer: C

Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.

4. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

A. The client is choking on part of the tube
B. The client has anxiety
C. The client is having a laryngospasm
D. The client is having a normal response from anesthesia

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

5. A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially the nurse should plan this for a manic client:

A. Set realistic limits to the client's behavior
B. Repeat verbal instructions as often as needed
C. Allow the client to express feelings to relieve tension
D. Assign staff to be with the client at all times to help maintain control

Correct answer: A

Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.