NCLEX-PN Test 1 Flashcards

Questions and Answers

What is an appropriate intervention for a client with paranoid delusions who refuses to eat?

Provide the client food in opened packages

Provide the client food in unopened, individually packaged food (correct)

Ignore the client's refusal

Force the client to eat in front of a nurse

Which pediatric client demonstrates signs of abuse that may necessitate mandatory reporting?

4-year-old with a bruise on the arm

5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures (correct)

3-year-old with a sprained ankle

6-year-old who frequently misses school

What is the best response by the nurse when a spouse becomes upset about a hospital bed for a client with Huntington disease?

What upsets you about having a hospital bed?

Which statement indicates that ondansetron was effective in a client?

The nausea is a lot better. Signup and view all the answers

Which client should the nurse see first?

Client receiving IV normal saline at 250 ml/hr who is reporting puffy legs and a new cough. Signup and view all the answers

How should the care of an unaccompanied 16-year-old girl with severe abdominal pain and vomiting be handled?

Administer care until the parents or guardians can be reached. Signup and view all the answers

Which statement by the parents indicates effective teaching regarding weaning from breastfeeding?

I can start substituting breastfeeding sessions with whole cow's milk. Signup and view all the answers

What is the most appropriate intervention when a client's adult child requests to override the DNR code status?

Explain the client's wishes to the adult child. Signup and view all the answers

What should the nurse ask a client diagnosed with schizophrenia who looks away and grimaces?

What do you see at the door? Signup and view all the answers

What priority information should be included during the initial prenatal visit for a 15-year-old primigravid client?

Stress the importance of consistent prenatal care. Signup and view all the answers

Which question helps determine a client's risk for sexually transmitted infections?

What barrier methods do you and your partner(s) use? Signup and view all the answers

What is the nurse's priority action when a client's chest tube drainage system is dislodged?

Firmly cover the insertion site with the palm of a clean, gloved hand. Signup and view all the answers

What stage of burn is indicated by an area that is red, moist, and covered in shiny, fluid-filled vesicles?

Second degree. Signup and view all the answers

Which client should the nurse see first in the emergency department?

Client with myasthenia gravis who has a fever and increasing difficulty swallowing. Signup and view all the answers

Which client statement indicates that the client is not currently at risk for suicide?

I plan to attend my granddaughter's graduation next month. Signup and view all the answers

What is the best response by the nurse for a client taking escitalopram who reports no improvement?

Let's talk more about how you have been taking this medication. Signup and view all the answers

Study Notes

Mental Health and Nursing Interventions

For clients with paranoid delusions refusing food, providing unopened, individually packaged food is appropriate to ensure safety and trust.
It is crucial to recognize signs of abuse in children, such as a 5-year-old with multiple fractures, which may require mandatory reporting.

End-of-Life and Advance Directives

Engaging clients' families about care needs in terminal stages can be sensitive; asking about their feelings regarding care items like hospital beds helps in understanding their emotional state.
If a client with DNR status stops breathing, explaining the client's wishes to a family member who changes their mind is essential.

Medication Administration and Assessment

The effectiveness of ondansetron for nausea can be indicated when a client reports improvement, such as feeling "a lot better."
In emergency scenarios, recognizing a client’s vital condition—like a 16-year-old with abdominal pain and a fever—should prompt continued care until guardians are reached.

Pediatric Health and Development

When reinforcing weaning from breastfeeding, parents should be informed that cow's milk is an acceptable substitute.
Consistent prenatal care is essential for pregnant clients, particularly those in their first trimester.

Sexual Health Assessment

Inquiring about barrier methods during sexual encounters helps assess risk for sexually transmitted infections in clients reporting same-sex relations.

Emergency Care and Prioritization

In case of chest tube dislodgment, the immediate action is to cover the insertion site with a clean, gloved hand to prevent air entering the pleural space.
Identifying critical conditions, such as a client with myasthenia gravis experiencing fever and swallowing difficulties, is vital for timely intervention.

Behavioral Assessment and Safety

Clients who express plans for future events, like attending a grandchild's graduation, often indicate reduced suicidal risk.
Monitoring medication adherence and discussing lack of improvement, such as with escitalopram, encourages a focus on the client's experience and medication management.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz consists of flashcards designed to help nursing students prepare for the NCLEX-PN exam. It includes scenarios involving patient care interventions, particularly in mental health and pediatric settings. Each card presents a situation followed by an appropriate nursing response, reinforcing critical thinking and knowledge application in nursing practice.