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

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?

A. Empathy
B. Self-disclosure
C. Disapproval
D. False reassurance

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. The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?

A. Early diagnosis and treatment provide the only means for a cure of ASD.
B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
D. Early diagnosis and treatment prevent your child from developing any other mental condition.

Correct answer: B

Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.

3. Which of the following is an example of a living will?

A. A client's son has been appointed to make his healthcare decisions if he becomes incapacitated
B. A client has designated which of his children will receive his home and property before he dies
C. A client has instructions that he does not want to be resuscitated through chest compressions if his heart stops beating
D. A client designates what type of burial or cremation services he would want after his death

Correct answer: C

Rationale: A living will is a type of advanced directive that a client develops to stipulate his preferences for healthcare in the event that he is unable to do so. This includes specific instructions about medical treatments in certain situations. Choice C is the correct answer as it reflects a scenario where the client has clearly outlined their preference regarding resuscitation through chest compressions. Choices A, B, and D do not pertain to a living will. Choice A involves a healthcare proxy or agent, choice B involves a will or estate planning, and choice D involves funeral or burial arrangements, which are not part of a living will.

4. Which of the following statements best describes compartment syndrome?

A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
D. An injury causes pain and swelling of the median plantar nerve.

Correct answer: B

Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.

5. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.

A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
C. The client should lie flat on their back for a specific period following the procedure.
D. The risks of the procedure include headache, back pain, and infection.

Correct answer: B

Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.