following an automobile accident that caused a head injury to an adult client the nurse observes that the client sleeps for long periods of time the n

NCLEX-PN

Nclex Questions Management of Care

1. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

A. hypothalamus.
B. thalamus.
C. cortex.
D. medulla.

Correct answer: A

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

2. What are the hazards of improper splinting?

A. Aggravation of a bone or joint injury
B. Reduced distal circulation
C. Delay in transporting a client with a life-threatening injury
D. All of the above

Correct answer: D

Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.

3. The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?

A. The LPN is assigned to care for a client with diabetes mellitus who needs instructions reinforced on how to self-administer insulin.
B. The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man.
C. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.
D. The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.

Correct answer: D

Rationale: The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.

4. A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?

A. shopping for groceries
B. house cleaning
C. transportation to physician's visits
D. medication instruction

Correct answer: D

Rationale: The correct answer is 'medication instruction.' This service involves educating the client on how to properly take their medications, which requires a certain level of expertise and skill. Grocery shopping, house cleaning, and transportation to physician's visits are considered unskilled services as they do not involve specialized knowledge or training. In contrast, medication instruction is a skilled service that necessitates specific training to ensure the client's safety and adherence to their medication regimen.

5. What should a client room environment include?

A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)

Correct answer: B

Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.