the depressed client verbalizes feelings of low self esteem and self worth typified by statements such as im such a failure i cant do anything right t

NCLEX-RN

NCLEX RN Exam Review Answers

1. The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:

A. To tell the client this is not true; that we all have a purpose in life.
B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
C. To reassure the client that you know how the client is feeling and that things will get better.
D. To identify recent behaviors or accomplishments that demonstrate skill ability.

Correct answer: C

Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.

2. Which of the following is an example of low health literacy skills?

A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
B. A client cannot read an admission form to sign it
C. A nurse cannot calculate the correct IV rate for Ringer's lactate
D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine

Correct answer: B

Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.

3. A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?

A. The registered nurse will be performing the procedure
B. The procedure takes approximately 1 ? hours.
C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
D. The infant will continue to receive phototherapy during the procedure.

Correct answer: B

Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.

4. What is the purpose of performing quality control?

A. Create a paper trail to show that the laboratory is compliant with OSHA standards for quality control.
B. Improve the odds that the results reported for any given test are as accurate and reliable as possible.
C. Be required by law to be part of a quality assurance program.
D. All of the above

Correct answer: B

Rationale: The primary purpose of performing quality control is to enhance the accuracy and reliability of test results. Quality controls are crucial for ensuring the reliability of each analyte tested. While quality control is not mandated by specific laws, accrediting bodies often require it to maintain accreditation. Creating a paper trail and legal requirements are not the primary objectives of quality control, making choices A and C incorrect. Therefore, the correct answer is to improve the accuracy and reliability of reported test results.

5. Victor, a 43-year-old patient who is HIV positive with a diagnosis of pneumocystis carinii pneumonia (PCP), has been admitted to the hospital. His prognosis is very poor, and his partner, Roger, would like to have a ceremony performed in his room to honor their union in case something happens to Victor, who agrees. What is the most appropriate response to their request?

A. Inform them that Victor is too ill for a ceremony
B. Ask the social worker to intervene
C. Tell them it's against hospital policy
D. Coordinate with other disciplines to support their request

Correct answer: D

Rationale: The most appropriate and compassionate response is to respect Victor and Roger's relationship and honor their wishes. Coordinating with other disciplines, such as social work, chaplaincy, or patient advocacy, to support their request demonstrates a holistic approach to care. This collaborative effort can facilitate the ceremony and provide emotional support to both Victor and Roger during a challenging time. Upholding their request aligns with the principles of patient-centered care and promotes dignity and respect, as outlined in the ANA Code of Ethics. Informing them that Victor is too ill for a ceremony (Choice A) would dismiss their emotional needs and fail to address their request. Involving the social worker without understanding the specific request (Choice B) may not directly address their desire for a ceremony. Telling them it's against hospital policy (Choice C) disregards the importance of honoring patient preferences and may cause unnecessary distress in an already sensitive situation.