NCLEX-RN Exam
Question 1 of 5.
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
A. Emphasize those aspects of the procedure that require cooperation.
B. Tell the child not to cry or yell.
C. Tell the child that he will get a 'stick'Â in his back.
D. Use medical terminology when explaining the procedure to the client.
Explanation: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 2 of 5.
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
A. Hamburger
B. Hot dog
C. Potato salad
D. Baked beans
Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.
Question 3 of 5.
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
A. Ineffective family coping related to parental role conflict
B. Care-giver role strain related to chronic situational stress
C. Altered family process related to impaired social interaction
D. Altered parenting related to impaired growth and development
Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.
Question 4 of 5.
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines for himself
Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 5 of 5.
The nurse has just received the change of shift report. Which client should the nurse assess first?
A. A client with a supratentorial tumor awaiting surgery
B. A client admitted with a suspected subdural hematoma
C. A client recently diagnosed with akinetic seizures
D. A client transferring to the neuro rehabilitation unit
Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.
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