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A registered nurse reviews a plan of care
developed by a nursing student for a
client with depression and notes a nurs-
ing diagnosis of impaired nutrition: less
than body requirements. The registered
D
nurse asks the student to revise the plan
- The client should be asked which foods
if which incorrect intervention is docu-
or drinks she likes, and consultation with
mented?
a dietitian also may be done. The client is
more likely to eat if the client has selected
a) offer small, high-calorie, high protein
the foods and is given foods that she
snacks frequently throughout the day
likes. Options A, B, and C are appropriate
and evening
interventions for the client with depres-
b) offer high protein, high-calorie flu-
sion with this nursing diagnosis.
ids frequently throughout the day and
evening
c) remain with the client during meals
d) complete the food menu for the client
during the depressed period
A
- When caring for a paranoid client,
the nurse must avoid any physical con-
A registered nurse reviews a plan of care
tact and should not touch the client. The
developed by a nursing student for client
nurse should ask the client's permission
with paranoia and notes a nursing diag-
if touch is necessary because touch may
nosis of Disturbed thought process. The
be interpreted as a physical or sexual
registered nurse asks the nursing stu-
assault. The nurse would use simple and
dent to revise the plan if which incorrect
clear language when speaking to the
intervention is documented?
client to prevent misinterpretation and to
clarify the nurse's intent and actions. A
a) sit with the client and hold the client's
warm approach is avoided because it
hand
can be frightening to a person who needs
b) avoid a warm approach when working
emotional distance. A matter-of-fact con-
with the client
sistency is nonthreatening. Any anger
c) use simple and clear language when
and hostile verbal attacks need to be
speaking to the client
diffused with a nondefensive stand. The
d) diffuse angry and hostile verbal at-
anger that a paranoid client expresses is
tacks with a nondefensive stand
often displaced, and when the staff be-
comes defensive, anger of both the client
and staff escalates. A nondefensive and
, Nursing Leadership and Management NCLEX Questions
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nonjudgmental attitude provides an atti-
tude in which feelings can be explored
more easily.
A registered nurse is discussing the
characteristics of anorexia nervosa with
a nursing student. The registered nurse
determines that the nursing student D
needs to further research this disorder - As anorexia nervosa develops, per-
if the student states that which of the sonal relationships tend to become more
following is a characteristic of anorexia superficial and distant. Social contacts
nervosa? are avoided because of the fear of being
invited to eat and being discovered. The
a) personal relationships tend to be- client is preoccupied with food and meal
come more superficial and distant planning (especially for others), personal
b) social contacts are avoided because caloric intake throughout the day, and
of the fear of being invited to eat and methods to avoid eating. Anorexic per-
being discovered sons are likely to become very emaciat-
c) the client is being preoccupied with ed and will not maintain their near-nor-
food and meal planning, especially for mal body weight.
others
d) the client will usually keep her weight
near normal
An experienced emergency department
nurse observes a new nurse employed
in the emergency department obtain B
the equipment needed to draw a blood - Isopropyl alcohol or any antiseptic solu-
sample for a blood alcohol level on a tion containing alcohol must not be used
client. The experienced emergency de- as a skin preparation before a blood al-
partment nurse intervenes if the new cohol specimen is drawn. These agents
nurse plans to use which item? may falsely elevate the blood alcohol lev-
el and render the test invalid. Option A,
a) tourniquet C and D identify items needed to obtain
b) alcohol swabs the blood specimen.
c) a blood-draw needle
d) a blood tube
A nurse administers digoxin (Lanoxin) C
0.25 mg instead of the prescribed order - The incident report is confidential and
of 0.125 mg. The nurse discovers the privileged information. It should not be