a nursing advocate is one who
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Nursing Elites

NCLEX-PN

Nclex Exam Cram Practice Questions

1. What does it mean to be a nursing advocate?

Correct answer: B

Rationale: A nursing advocate does not make decisions for others but instead empowers individuals to make decisions for themselves. By encouraging individuals to make their own decisions and supporting them in this process, nursing advocates uphold the principle of self-determination. This approach respects the autonomy and independence of individuals in managing their care. Therefore, the correct answer is to 'encourage persons to make decisions for themselves and act with or on behalf of the person to support those decisions.' Choices A, C, and D are incorrect as they do not align with the role of a nursing advocate in promoting patient autonomy and self-determination.

2. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?

Correct answer: A

Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.

3. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?

Correct answer: A

Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.

4. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up?

Correct answer: B

Rationale: A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6�F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.

5. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

Correct answer: D

Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.

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