at a community health fair the blood pressure of a 62 year old client is 16096 mmhg the client states my blood pressure is usually much lower the nurs

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

A. Go get a blood pressure check within the next 15 minutes
B. Check blood pressure again in two (2) months
C. See the healthcare provider immediately
D. Visit the healthcare provider within one (1) week for a BP check

Correct answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

2. After a lengthy explanation of a medical procedure, the patient asks many questions. The physician answers all of the questions to the best of their ability. The patient then gives consent for treatment. The costly equipment and supplies are put into place, and the patient is prepared. Two minutes before the procedure is to start, the patient begins panicking and changes their mind. Which of the following situations would be the best way to avoid litigation?

A. Document that the patient originally gave consent and proceed if the benefits of the procedure outweigh the patient's wishes.
B. Have the patient sign a form stating that they are refusing consent. If they refuse to sign, do not proceed with the procedure.
C. Repeat the explanation of the procedure until the patient understands that having the procedure done is the best form of treatment. Do not proceed with the procedure.
D. Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.

Correct answer: D

Rationale: In this scenario, the best course of action to avoid litigation is to respect the patient's right to refuse treatment, especially when changing their mind before the procedure starts. By not proceeding with the treatment, documenting the patient's refusal, and having the patient sign a refusal to consent form, you are following proper ethical and legal procedures. If the patient refuses to sign the form, having a witness available to sign further strengthens the documentation of the patient's decision. This approach ensures that the patient's autonomy and right to make informed decisions about their healthcare are respected. Choices A, B, and C do not prioritize the patient's right to refuse treatment and could potentially lead to legal issues if treatment is carried out against the patient's wishes.

3. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

A. Confront the delusional material directly by telling Gio that this simply is not so.
B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
D. Isolate Gio when he begins to talk about these beliefs.

Correct answer: B

Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.

4. Which of the following is an example of intragroup conflict?

A. A nurse writes a grant for a non-profit organization to raise money for advertising
B. Members of a multidisciplinary team cannot agree on the best course of action for a client
C. A client does not receive his medication on time because the nurse was on break
D. A nurse feels frustrated that her employer does not provide on-site child care

Correct answer: B

Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.

5. A woman has died as a result of a motor vehicle accident. She is listed as an organ donor, and her family is considering whether to comply with her wishes. Which of the following is true?

A. The woman would have had to list herself as an organ donor and notify her family before her death that she has considered donating her organs.
B. The Uniform Anatomical Gift Act requires the physician caring for the patient to inform the family who receives the donor organs.
C. Physicians can choose to go against the deceased's wishes if the family decides that organ donation is not an acceptable choice.
D. Physicians have the legal responsibility to inform patients of the risks involved in donating organs.

Correct answer: D

Rationale: In cases where a deceased person is listed as an organ donor, the family may have the final say on whether to proceed with organ donation, even if the individual had expressed their wish to donate. Physicians may prioritize the emotional well-being of the family over the wishes of the deceased, especially if organ donation could cause additional distress or trauma to the grieving family members. Therefore, it is possible for physicians to respect the family's decision not to proceed with organ donation, even if the deceased had previously expressed the desire to donate. This decision-making process underscores the importance of considering and respecting the perspectives and emotions of both the deceased individual and their surviving family members in organ donation scenarios.