Questions and Answers
What is an appropriate intervention for a client with paranoid delusions who refuses to eat?
Which pediatric client demonstrates signs of abuse that may necessitate mandatory reporting?
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?
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Which client should the nurse see first?
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How should the care of an unaccompanied 16-year-old girl with severe abdominal pain and vomiting be handled?
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Which statement by the parents indicates effective teaching regarding weaning from breastfeeding?
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What is the most appropriate intervention when a client's adult child requests to override the DNR code status?
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What should the nurse ask a client diagnosed with schizophrenia who looks away and grimaces?
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What priority information should be included during the initial prenatal visit for a 15-year-old primigravid client?
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Which question helps determine a client's risk for sexually transmitted infections?
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What is the nurse's priority action when a client's chest tube drainage system is dislodged?
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What stage of burn is indicated by an area that is red, moist, and covered in shiny, fluid-filled vesicles?
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Which client should the nurse see first in the emergency department?
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Which client statement indicates that the client is not currently at risk for suicide?
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What is the best response by the nurse for a client taking escitalopram who reports no improvement?
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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.
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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.