while walking in the hallway of an acute care unit of the hospital the nurse overhears the change of shift report the nurse should

NCLEX-PN

2024 Nclex Questions

1. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?

A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
C. Return to their own unit and not disclose that confidential information has been overheard.
D. Ignore the situation.

Correct answer: A

Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.

2. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?

A. "My sister still has episodes of crying, and it's been 3 months since Daddy died."?
B. "Sally seems to have forgotten the bad things that Daddy did in his lifetime."?
C. "She really had a hard time after Daddy's funeral. She said that she had a sense of longing."?
D. "Sally has not been sad at all about Daddy's death. She acts like nothing has happened."?

Correct answer: D

Rationale: Abnormal grieving is often characterized by a lack of sadness or acknowledgment of the loss. In this scenario, the statement 'Sally has not been sad at all about Daddy's death. She acts like nothing has happened' indicates abnormal grieving as it suggests a lack of emotional response or denial of the death. On the other hand, choices A, B, and C all describe normal grieving reactions: crying episodes, selective memory of the deceased, and feelings of longing after the funeral. These responses are typical in the grieving process. Therefore, choice D is the correct answer, highlighting a potential abnormality in the grieving process.

3. When assessing a client's self-expectations about weight loss, which question is most appropriate?

A. "What makes you think you can change your eating habits?"?
B. "How do you feel about losing weight?"?
C. "How important is it that you lose weight?"?
D. "What do you think is a realistic weekly weight loss for you?"?

Correct answer: D

Rationale: When assessing a client's self-expectations about weight loss, it is crucial to inquire about what the client considers a realistic weekly weight loss goal. This question helps in understanding the client's perception and expectations regarding the weight loss journey, enabling the establishment of achievable goals. Choices A, B, and C do not directly address the aspect of setting realistic goals for weight loss. While questioning about changing eating habits, feelings about losing weight, or the importance of weight loss are relevant, they do not specifically focus on setting achievable goals, which is essential for effective weight management.

4. In which age group does the highest incidence of child abuse occur?

A. Birth-3 years old
B. 4-6 years old
C. 6-10 years old
D. More than 10 years old

Correct answer: A

Rationale: The correct answer is 'Birth-3 years old.' Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). This age group is most vulnerable due to their dependency and inability to report or protect themselves effectively. Child abuse can occur at any age, but statistics show that infants and toddlers are at the highest risk due to their developmental stage and reliance on caregivers. Choices B, C, and D are incorrect because while child abuse can happen at any age, the prevalence is highest among children in the 0-3 age group.

5. A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about

A. the pathophysiology and behavioral manifestations of schizophrenia.
B. support groups that can help the parents cope with their frustration.
C. the prolonged recovery time and side effects of medications to prevent relapse.
D. motivational techniques that are effective in engaging clients with schizophrenia.

Correct answer: C

Rationale: The nurse conducting discharge teaching must emphasize the extended recovery process and the potential side effects of medications used to prevent relapse in individuals with schizophrenia. In this scenario, it is crucial for the parents to understand that the client's behavior may be influenced by the medication's sedative qualities and the time required for full recovery. While support groups can assist caregivers in coping with their emotions and providing better care, the priority here is educating on the recovery process and medication effects. Motivational techniques are beneficial but may not be the immediate focus in this situation.