the family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold what objective in
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Review Answers

1. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?

Correct answer: B

Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.

2. A patient is being seen in the crisis unit reporting that poison letters are coming in the mail. The patient has no history of psychiatric illness. Which group of the following medications would the patient most likely be started on?

Correct answer: A

Rationale: In this scenario, where a patient without a history of psychiatric illness is experiencing psychotic symptoms like believing in poison letters, the most suitable medication group to start the patient on would be atypical antipsychotics. Aripiprazole (Abilify) belongs to this group and is preferred due to its efficacy with fewer side effects compared to conventional antipsychotics. Risperidone (Risperdal Consta) is also an atypical antipsychotic but is usually indicated after stabilizing the patient with oral medications. Fluphenazine (Prolixin) is a conventional antipsychotic, which is less favored due to its side effect profile. Fluoxetine (Prozac) is an antidepressant and is not the first-line treatment for psychotic symptoms.

3. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

Correct answer: C

Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.

4. What ethical principle has led to the need for informed consent?

Correct answer: A

Rationale: Autonomy is the ethical principle that emphasizes an individual's right to make their own decisions if they are mentally competent. Informed consent is a direct result of this principle, as it ensures that patients are fully informed before agreeing to any medical intervention. Autonomy is crucial in healthcare as it respects patients' rights and promotes self-determination. Justice, fidelity, and beneficence are important ethical principles in healthcare, but they do not directly lead to the need for informed consent. Justice focuses on fairness and equal treatment, fidelity on trustworthiness and loyalty, and beneficence on doing good for the patient's benefit.

5. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?

Correct answer: C

Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.

Similar Questions

Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
Which of these devices is considered a protective device, rather than a restraint?
A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses