which information given by a 70 year old patient during a health history indicates to the nurse that the patient should be screened for hepatitis c
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NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

Correct answer: B

Rationale: The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.

2. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent?

Correct answer: B

Rationale: In healthcare settings, privacy regulations prevent professionals from discussing patient situations with individuals not involved in that patient's care. Maintaining patient confidentiality is crucial to protect sensitive information. In this scenario, sharing details about Jack's situation with the parent who overheard the conversation would breach confidentiality. It is important to handle such situations delicately, especially in emotional environments like intensive care unit waiting rooms. While empathy and support are essential, it is equally crucial to respect patient privacy and confidentiality. Therefore, responding with 'I can't discuss another patient's situation' is the most appropriate and professional response in this context.

3. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

Correct answer: C

Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.

4. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?

Correct answer: D

Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.

5. A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?

Correct answer: D

Rationale: In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.

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