which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

A. "I can always trust my family."?
B. "It seems like I always have bad luck."?
C. "You never know who will turn against you."?
D. "I hear evil voices that tell me to do bad things."?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

2. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

A. Send a text to the client to confirm the location of the house
B. Leave her purse and valuables on the seat in the car and lock the doors
C. Ask the client to keep an extra set of keys in case the car is locked
D. Keep the car windows rolled up when in an unfamiliar environment

Correct answer: D

Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security. Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety. Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety. Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.

3. The mitral valve is synonymous with the term:

A. Left ventricle
B. Right atrium
C. Bicuspid valve
D. Tricuspid valve

Correct answer: C

Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.

4. What action by the nurse is appropriate when examining a 16-year-old male teenager?

A. Discuss health teaching with the teenager to promote wellness.
B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Correct answer: D

Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.

5. Which of the following statements best describes footdrop?

A. The foot is permanently fixed in the dorsiflexion position
B. The foot is permanently fixed in the plantar flexion position
C. The toes of the foot are permanently fanned
D. The heel of the foot is permanently rotated outward

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.