NCLEX-PN
Nclex Questions Management of Care
1. What is involved in client education by the nurse?
- A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
- B. Giving information to the client that is accurate and understandable.
- C. Informing the client that the pain they experience might not be real.
- D. Administering medication to the client when they experience pain.
Correct answer: B
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
2. When are standard walkers typically used?
- A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
- B. When clients have poor balance, have a broken leg, or have experienced amputation.
- C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. When clients have poor balance, have an autoimmune disease, or have weak arms.
Correct answer: C
Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.
3. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
4. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
- A. grief work facilitation
- B. vital signs monitoring
- C. medication administration: skin
- D. anxiety reduction
Correct answer: A
Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'
5. How should an infant be secured in a car?
- A. To hold the infant while sitting in the middle of the back seat of the car
- B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
- C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
- D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat
Correct answer: D
Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.
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