all hospitals and nursing homes are mandated to have the goal of a restraint free environment the best way to achieve this goal is to
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. All hospitals and nursing homes are mandated to have the goal of a restraint-free environment. The best way to achieve this goal is to ________________.

Correct answer: B

Rationale: All hospitals and nursing homes are mandated by JCAHO and state departments of health to have the goal of a restraint-free environment. This does not mean that no restraints can ever be used under any circumstances. The goal is to minimize the use of restraints and prioritize other preventive measures. Restraining a patient should only be considered when all other preventive strategies have failed, and the patient is at risk of harm. Therefore, the best approach is to limit the use of restraints to situations where falls cannot be prevented, ensuring that restraints are used as a last resort to maintain patient safety. Choices C and D are not ideal solutions as they do not address the appropriate use of restraints in a restraint-free environment.

2. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

Correct answer: B

Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.

3. A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:

Correct answer: A

Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.

4. A client must use a non-rebreathing oxygen mask. Which of the following statements is true regarding this type of mask?

Correct answer: A

Rationale: A non-rebreather mask is used for supplemental oxygen delivery for clients experiencing breathing difficulties. The non-rebreather mask includes a one-way valve that allows exhaled air to escape, preventing the rebreathing of carbon dioxide. The client inhales oxygenated air from a reservoir bag attached to the mask, providing high-concentration oxygen therapy. A non-rebreather mask can deliver FiO2 levels of up to 90%, making it an effective intervention for clients requiring high oxygen concentrations. Therefore, the statement that 'A non-rebreather can provide an FiO2 of 40%' is correct. Choices B, C, and D are incorrect because clients should breathe through their nose and mouth, the mask offers a reservoir for inhaling oxygen, and the mask should be assessed and potentially replaced if soiled or damaged, not routinely changed every 3 hours.

5. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:

Correct answer: C

Rationale: It is important for the nurse to validate the patient's concerns and provide a supportive environment. By acknowledging that it is normal for young adults to have questions about sexuality, the nurse helps the patient feel understood and accepted. This response encourages further discussion and exploration of the patient's feelings without judgment. Choice A dismisses the patient's concerns and implies that his feelings are not valid. Choice B stigmatizes the patient's feelings by labeling them as abnormal and suggests therapy without proper assessment. Choice D addresses the patient's feelings but lacks the validation and reassurance present in the correct answer, which is essential in building a trusting relationship with the patient.

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