an 18 year old male patient informs the nurse that he isnt sure if he is homosexual because he is attracted to both genders the nurse establishes a tr
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. 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: C

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.

2. 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?

Correct answer: B

Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.

3. A client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client to sign an AMA order, the client refuses and leaves. What is the next action of the nurse?

Correct answer: D

Rationale: The nurse cannot force the client to stay in the hospital to receive treatment or to sign an AMA order. It is essential to respect the client's autonomy and decision-making capacity. While involving security or pressuring the client through the physician or spouse may seem like options, they are not appropriate in this situation. The nurse should allow the client to leave if they are competent to make that decision, document the refusal in the client's chart to ensure all actions are appropriately documented, and follow institutional policies for patients leaving against medical advice.

4. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?

Correct answer: D

Rationale: A significant disadvantage of implementing a new electronic charting program is the potential for complexity and difficulty in implementation. Introducing a new system requires time and education for staff to adapt and use it appropriately. Users may experience confusion as they learn to navigate the new charting techniques, which can impact workflow efficiency and accuracy. Option A is incorrect because electronic charting systems are designed to enhance data security and integrity, reducing the risk of information being lost or misused. Option B is incorrect as access control mechanisms can restrict who can view specific patient records. Option C is incorrect as electronic charting systems often facilitate communication between healthcare providers by providing real-time access to patient information.

5. A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?

Correct answer: B

Rationale: In disseminated intravascular coagulation (DIC), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (Choice A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (Choice C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (Choice D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots. Therefore, the correct answer is a prolonged PT.

Similar Questions

A nurse is using active listening as a form of therapeutic communication when:
The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
Family members of a patient ask repeated questions about the monitors and various readings in the patient's room. What is the most supportive response to their questions?
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