a client in a long term care facility tells the nurse my daughter never visits me the nurse responds by telling the client that when her own mother wa
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Review Answers

1. A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?

Correct answer: B

Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.

2. Which action represents the evaluation stage of the plan of care?

Correct answer: C

Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.

3. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:

Correct answer: C

Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.

4. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.

Correct answer: C

Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.

5. When a mother is inquiring about her child's ability to potty train, what is the most critical aspect of toilet training?

Correct answer: C

Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.

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