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 must use a non-rebreathing oxygen mask. Which of the following statements is true regarding this type of mask?

Correct answer: A

Rationale: A non-rebreather mask is used for supplemental oxygen delivery for clients experiencing breathing difficulties. The non-rebreather mask includes a one-way valve that allows exhaled air to escape, preventing the rebreathing of carbon dioxide. The client inhales oxygenated air from a reservoir bag attached to the mask, providing high-concentration oxygen therapy. A non-rebreather mask can deliver FiO2 levels of up to 90%, making it an effective intervention for clients requiring high oxygen concentrations. Therefore, the statement that 'A non-rebreather can provide an FiO2 of 40%' is correct. Choices B, C, and D are incorrect because clients should breathe through their nose and mouth, the mask offers a reservoir for inhaling oxygen, and the mask should be assessed and potentially replaced if soiled or damaged, not routinely changed every 3 hours.

3. A victim of a gunshot wound to the abdomen has been admitted to the hospital, accompanied by a police officer. When questioned, the officer states that the patient is a suspect in a homicide, which occurred as part of the same incident. A small child was killed as the result of a stray bullet. The patient is combative, yells that he's in pain and demands medication. What is your most appropriate response?

Correct answer: C

Rationale: The most appropriate and caring response is to perform a pain assessment and administer the pain medication that has been ordered. Regardless of personal feelings about any given situation, the nurse's responsibility is to provide unbiased, appropriate, and supportive care, as stated in the American Nurses Association (ANA) Code of Ethics. Choice A is not appropriate as it disregards the patient's immediate need for pain relief. Choice B may escalate the situation and is not the priority in this case. Choice D is not the immediate action needed to address the patient's pain and distress.

4. A nurse is using active listening as a form of therapeutic communication when:

Correct answer: C

Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.

5. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

Correct answer: B

Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.

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