which of the following needs immediate medical attention and emergency intervention the client who

NCLEX-PN

Quizlet NCLEX PN 2023

1. Which of the following needs immediate medical attention and emergency intervention? The client who:

A. complains of sharp pain upon taking a deep breath and excessive coughing.
B. exhibits yellow, productive sputum, low-grade fever, and crackles.
C. has a shift of the trachea to the left, with no breath sounds on the right.
D. has asthma and complains of an inability to catch her breath after exercise.

Correct answer: C

Rationale: Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.

2. Which of the following situations requires nurse intervention?

A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves while shaving her legs.'
B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'

Correct answer: C

Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.

3. Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?

A. Place the child in a private room
B. Gowns and masks must be worn by all personnel in the child's room
C. Visitors are restricted to parents only
D. Hand washing is required by all personnel and visitors having contact with the child

Correct answer: B

Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.

4. How can a diet high in fiber content benefit an individual?

A. aid in weight loss.
B. reduce diabetic ketoacidosis.
C. lower cholesterol.
D. reduce the need for folate.

Correct answer: C

Rationale: A diet high in fiber content can help lower cholesterol levels by reducing the absorption of cholesterol in the bloodstream. Fiber-rich foods, like grains, apples, potatoes, and beans, can aid in this process. While fiber can aid in weight loss by promoting a feeling of fullness and aiding digestion, it is not primarily for fast weight loss. Fiber does not directly reduce the risk of diabetic ketoacidosis, which is more related to managing blood sugar levels through insulin therapy and dietary control. Folate is a B vitamin that is essential for various bodily functions and is not influenced by fiber intake. Therefore, the correct answer is to lower cholesterol, as fiber plays a significant role in this benefit.

5. If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

A. Conveying calmness through one-on-one interaction
B. Recognizing and managing your own feelings to prevent escalation of the patient's anxiety level
C. Encouraging client participation in group therapy
D. Listening and identifying causes of their behavior

Correct answer: C

Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms. Choices A, B, and D are appropriate interventions. Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety. Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms. Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.