NCLEX-PN
Nclex Questions Management of Care
1. Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.
2. Which of the following statements describes the purpose of client restraint?
- A. Restraints are a nursing measure used to maintain client control.
- B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
- C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
- D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
Correct answer: B
Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.
3. The client has asked if you would be able to offer any alternative or complementary therapy during their hospitalization. Which of the following would be appropriate to suggest?
- A. Physical therapy
- B. Music therapy
- C. Psychiatric therapy
- D. Occupational therapy
Correct answer: B
Rationale: Music therapy is an appropriate suggestion as an alternative or complementary therapy during hospitalization. Music therapy can help improve the client's condition and comfort level by providing emotional support and reducing stress. Physical therapy and occupational therapy are crucial for rehabilitation and improving physical function, while psychiatric therapy focuses on mental health treatment. These therapies are essential components of care but are not typically considered alternative or complementary therapies in this context.
4. Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?
- A. "I cannot eat or drink after midnight."?
- B. "I cannot eat for 12 hours before the test."?
- C. "I need to limit my fluid intake."?
- D. "I need to ingest a lipid solution."?
Correct answer: B
Rationale: The correct statement regarding preparation for a lipoprotein fractionation test is that the client cannot eat for 12 hours before the test. It is important to note that the client can drink an unrestricted amount of water. Limiting fluid intake is not necessary for this test. There is no need for the client to ingest a lipid solution as part of the preparation. Therefore, the other choices are incorrect.
5. All of the following are causes of vaginal bleeding in late pregnancy except:
- A. Placenta previa.
- B. Eclampsia.
- C. Abruptio placentae.
- D. Uterine rupture.
Correct answer: B
Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.
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