aclient comes to the clinic for assessment ofhis physical status and guidelines for starting a weight reduction diet the clients weight is 216 pounds
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NCLEX-PN

NCLEX PN 2023 Quizlet

1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.

2. At what age will vision be 20/20 in children?

Correct answer: C

Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.

3. What advice should be given to a client with stress incontinence?

Correct answer: A

Rationale: For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.

4. Which client should be seen first by the Emergency Department nurse?

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

5. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.

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