the nurse is assisting the rn with discharge instructions for a client with an implantable de ibrillator what discharge instruction is essential
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NCLEX-PN

PN Nclex Questions 2024

1. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential?

Correct answer: C

Rationale: The essential discharge instruction for a client with an implantable defibrillator is to use any battery-operated machinery on the opposite side, including cellphones. This is to prevent interference with the device. Additionally, the client should monitor their pulse rate and report any dizziness or fainting, which could indicate issues with the defibrillator. Choices A, B, and D are incorrect because clients with implantable defibrillators can eat food prepared in the microwave, move their shoulder on the affected side after the initial healing period, and are allowed to fly on commercial airliners with the defibrillator in place.

2. In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

Correct answer: B

Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.

3. How does the ANA define the psychiatric nursing role?

Correct answer: A

Rationale: The correct answer aligns with the ANA's definition of the psychiatric nursing role. According to the ANA, psychiatric nursing is a specialized area of nursing practice that incorporates theories of human behavior as its foundational science and utilizes the self as its essential art. This definition emphasizes the importance of understanding human behavior and leveraging therapeutic communication and relationships to provide effective care for individuals with mental health concerns. Choices B, C, and D are incorrect because they do not accurately represent the ANA-defined role of psychiatric nursing. Psychiatric nurses primarily focus on delivering holistic care, promoting mental health, and supporting individuals with mental health challenges using evidence-based practices and therapeutic interventions.

4. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?

Correct answer: B

Rationale: The correct answer is 'Mania.' A client with a serum sodium level of 170 meq/L has hypernatremia, which can lead to manic behavior. Hypernatremia is associated with irritability, restlessness, confusion, and in severe cases, manic symptoms. Choices A, C, and D (Anger, Depression, Psychosis) are not typically associated with hypernatremia and are, therefore, incorrect in this context.

5. During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:

Correct answer: A

Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.

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