while undergoing fetal heart monitoring a pregnant native american woman requests that a medicine woman be present in the examination room which of t

NCLEX-PN

Nclex Exam Cram Practice Questions

1. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

A. "I will assist you in arranging to have a medicine woman present."?
B. "We do not allow medicine women in exam rooms."?
C. "That does not make any difference in the outcome."?
D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.

2. How does cancer affect pain tolerance in elderly clients?

A. Remain constant.
B. Decrease.
C. Increase.
D. Cancer has no impact on pain tolerance in elderly clients.

Correct answer: B

Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance. Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.

3. What intervention should the nurse take for a client who has sustained a hyphema?

A. Instruct the client to wear eye protectors in the future
B. Keep the client at bed rest, typically with the head of the bed propped up
C. Apply atropine eyedrops
D. Apply an ice pack to the site of injury

Correct answer: B

Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.

4. Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?

A. "I should provide a regular schedule for toileting."?
B. "I should talk to my father less because he can't communicate."?
C. "I should give my father oral care after every meal and bedtime."?
D. "I should assist my father with eating and drinking."?

Correct answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

5. In which situation is the nurse upholding the ethical principle of fidelity?

A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
B. Allowing a client to decide when to receive daily hygiene care
C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

Correct answer: D

Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.