you are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying you are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying
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Nursing Elites

NCLEX NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?

Correct answer: Skin breakdown

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

2. Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?

Correct answer: D: I explain the reason for the time-out before and after disciplining my child.

Rationale: The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child’s association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child’s trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.

3. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?

Correct answer: Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.

Rationale: The correct action for the nurse to take in this situation is to inform the surgeon that the operative permit is not signed and that the client has questions about the surgery. It is the responsibility of the surgeon to explain the procedure to the client and obtain the client's signature on the permit. While the nurse can witness the client's signature on the permit, the procedure must first be explained by the healthcare provider or surgeon, including addressing the client's questions. Therefore, informing the surgeon is the priority to ensure proper communication and consent before the surgery. Answering the client's questions about the surgery (Choice B) may not provide accurate information and could lead to misunderstanding. Reassuring the client (Choice D) is important, but obtaining proper consent and addressing concerns should come first. Witnessing the client's signature (Choice A) is not sufficient if the client has unanswered questions and the permit is not signed.

4. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:

Correct answer: At your age, it is normal to be curious about both genders.

Rationale: It is important for the nurse to validate the patient's concerns and provide a supportive environment. By acknowledging that it is normal for young adults to have questions about sexuality, the nurse helps the patient feel understood and accepted. This response encourages further discussion and exploration of the patient's feelings without judgment. Choice A dismisses the patient's concerns and implies that his feelings are not valid. Choice B stigmatizes the patient's feelings by labeling them as abnormal and suggests therapy without proper assessment. Choice D addresses the patient's feelings but lacks the validation and reassurance present in the correct answer, which is essential in building a trusting relationship with the patient.

5. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?

Correct answer: Ask about the nurse's personal beliefs about family support during hospitalization.

Rationale: The first step in providing culturally competent care is to understand one's own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse's frustration. The remaining responses, such as suggesting that the nurse ask family members to leave the room or having the nurse explain to the family that too many visitors will tire the patient, are not culturally appropriate for this patient.

Similar Questions

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?
The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
The client has a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?
Which of the following is an advantage of working with psychiatric clients in a group setting?

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