a nurse caring for a pediatric client shows little concern when the parents attempt to speak with her about their daughters illness when approached by

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. A nurse caring for a pediatric client shows little concern when the parents attempt to speak with her about their daughter's illness. When approached by the nurse manager about her behavior, the nurse responds by saying, 'I don't want to get involved. It doesn't matter what I do anyway; my work does not make much of a difference.' This nurse is exhibiting which of the following characteristics?

A. Objectivity
B. Depersonalization
C. Procrastination
D. Disruption

Correct answer: B

Rationale: The correct answer is 'Depersonalization.' A nurse who distances themselves from clients to avoid emotional involvement is displaying depersonalization. This behavior is often seen in nurses experiencing burnout due to stress. Depersonalization can stem from low morale, moral distress, and may serve as a defense mechanism to cope with stress and emotional exhaustion. It is a way to shield oneself from feeling overwhelmed by the burdens of caring for others. Choice A, 'Objectivity,' is incorrect because objectivity involves maintaining a neutral and unbiased perspective, which is not the case here. Choice C, 'Procrastination,' is incorrect as it refers to delaying tasks, not emotional distancing. Choice D, 'Disruption,' is irrelevant to the scenario described and does not align with the nurse's behavior of detachment and lack of concern.

2. Which of the following clients have barriers to accessing healthcare?

A. A 36-year-old client who must use a wheelchair for mobility
B. A 44-year-old client who is visiting the United States on a visa from India
C. An 81-year-old client who is unable to drive
D. All of the above

Correct answer: D

Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.

3. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

A. Abdominal respirations
B. Inspiratory grunt
C. Nasal flaring
D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

4. A physician has written an order for '2.0 mg MS q 2-4 hr prn pain.' What is the nurse's appropriate response to this order?

A. Give 2 mg of morphine sulfate to the client
B. Give 20 mg of morphine sulfate to the client
C. Contact the pharmacy to clarify the order
D. Contact the physician to rewrite the order

Correct answer: D

Rationale: The physician's order contains several errors that could lead to potential harm to the client if not addressed. The use of '2.0' involves a trailing decimal point, which may lead to confusion regarding the intended dose of the drug. Additionally, the abbreviation 'MS' is considered a Do Not Use abbreviation by the Joint Commission, as it could refer to morphine sulfate or magnesium sulfate, leading to medication errors. While the order indicates the drug should be used for pain, the nurse should contact the physician to clarify the exact dose and specific drug to be administered, ensuring safe and accurate medication administration. Therefore, the correct response is to contact the physician to rewrite the order.

5. The key to the prevention of a pandemic influenza is:

A. Early detection
B. Early antibiotic treatment
C. Vaccination of at-risk populations
D. Isolation of suspected cases

Correct answer: A

Rationale: The key to preventing a pandemic influenza is early detection. Detecting influenza cases early allows for timely public health responses to limit the spread of the virus. Early detection helps in implementing measures such as isolation, treatment, and vaccination to prevent the development of a full-blown pandemic. Antibiotics are not effective against influenza viruses, so early antibiotic treatment is not the key to prevention. While vaccination of at-risk populations is important in controlling the spread of influenza, early detection is crucial as it allows for timely implementation of vaccination strategies. Isolation of suspected cases is a containment measure rather than a prevention strategy; the key to prevention lies in early detection to stop the spread before it becomes a pandemic.