the nurse is caring for a client following an appendectomy the client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale the

NCLEX-PN

NCLEX PN 2023 Quizlet

1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?

A. Answer any questions the employer may have as he pays for the insurance.
B. Tell the employer his question is inappropriate and that the information is none of his business.
C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
D. Ask the employer to leave and wait until the client returns home to visit.

Correct answer: C

Rationale: The appropriate nurse response is to explain to the employer that private information cannot be released and ask the employer to step out while conducting the assessment. This approach respects the client's privacy while still acknowledging the employer. The employer's payment for insurance does not grant rights to confidential information. Sharing information without permission violates the client's right to privacy under HIPAA. Option A is incorrect as it compromises the client's confidentiality by sharing private medical information. Option B is inappropriate and unprofessional as it does not address the situation respectfully. Option D is incorrect as it does not prioritize the client's immediate needs and assumes the client's consent without proper communication.

2. A 62-year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an overdose?

A. Lower extremity edema
B. Sensory changes in the upper extremities
C. Increased occurrence of fractures
D. Decreased peripheral blood flow

Correct answer: A

Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.

3. A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?

A. The patient is excited about being around family again.
B. The patient's suicide plan has probably progressed.
C. The patient's plans for the future have been clarified.
D. The patient's mood is improving.

Correct answer: B

Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.

4. Which hormone is responsible for amenorrhea in the pregnant woman?

A. Progesterone
B. Estrogen
C. Follicle-stimulating hormone (FSH)
D. Human chorionic gonadotropin (hCG)

Correct answer: A

Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.

5. Which of the following viruses is most likely to be acquired through casual contact with an infected individual?

A. influenza virus
B. herpes virus
C. cytomegalovirus (CMV)
D. human immunodeficiency virus (HIV)

Correct answer: A

Rationale: The correct answer is influenza virus. Influenza virus is most likely to be acquired through casual contact with an infected individual as it is transmitted through respiratory droplets. Herpes virus is primarily transmitted by direct contact, such as skin-to-skin contact, making it less likely to be acquired through casual contact. HIV is mainly transmitted through blood and body fluids like semen and vaginal fluids, not through casual contact. Cytomegalovirus (CMV) is an opportunistic infection commonly affecting immunocompromised individuals and is usually transmitted through close personal contact, not casual contact.