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NCLEX Question of The Day
1. The schizophrenic client tells you that they are “Jesus” and “there to save the world”. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not “Jesus”.
- D. Ask the client to share with the group how he knows that he is “Jesus”.
Correct answer: Set limits and send the client to their room.
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are “Jesus” (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
2. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. What is the most appropriate course of action for the nurse?
- A. Request the female’s parents for a private evaluation of her scalp
- B. Contact the female’s parents regarding the observations
- C. Observe the hairline and scalp for possible signs of lice
- D. Inform the student’s physician about the situation
Correct answer: C
Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.
3. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
- A. maintaining adequate tissue perfusion
- B. demonstrating behaviors that reduce fears
- C. restored body integrity
- D. remaining free of infection
Correct answer: restored body integrity
Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.
4. Which isolation procedure will be followed for secretions and blood?
- A. Respiratory Isolation
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet Isolation
Correct answer: Standard Precautions
Rationale: The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (Choice A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (Choice C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (Choice D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.
5. 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: 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.
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.
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