NCLEX Client Needs Lippincott Prep-U

A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest? a) Take stress-management classes. b) Change jobs. c) Spend more time with his family. d) Leave work at work. - Take stress management class. Rationale: The nurse should suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach him how to manage stress more effectively. The client may not have to leave a job he enjoys. The information provided by the client doesn't indicate that spending too little time with his family and taking his job home with him contribute to the client's stress. A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ice cream. b) ground beef patties. c) fresh orange slices. d) steamed broccoli. - ground beef patties. Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true? a) The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye. b) The client can read at a distance of 30′ (9 m) what a person with normal vision can read at a distance of 40′. c) The client can read the entire vision chart at a distance of 40′ (12 m). d) The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. - The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Rationale: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read A nurse is providing care for a pregnant 16-year-old. The client says that she is concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: a) "The prenatal vitamins should ensure the baby gets all the necessary nutrients." b) "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." c) "Now isn't a good time to begin dieting because you are eating for two." d) "Let's explore your feelings further." - "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." Rationale:Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this issue with the client. The client isn't eating for two; this belief is a misconception. Exploring feelings helps the client understand her concerns, but the nurse also needs to make the client aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or developing fetus needs; they work in conjunction with a balanced diet. A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? a) Evaluation for signs and symptoms of increased intracranial pressure (ICP) b) Lung auscultation and measurement of vital capacity and tidal volume c) Evaluation of nutritional status and metabolic state d) Evaluation of pain and discomfort - Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities. An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals blood pressure (BP) 160/78, heart rate (HR) 102 beats per minute, and respiration rate 32 breaths per minute with audible wheezing. Which of the following is the nurse's priority action?a) Administer 100% oxygen via mask b) Assess the site to remove the stinger c) Assist the client to lie down d) Assess the client's airway - Assess the client's airway Explanation: All of the answers may need to be done for this client, but the initial priority action for any client with an elevated respiratory rate and wheezing is to assess and maintain the airway. When integrating the concepts underlying the cognitive-behavioral model into a client's plan of care, the nurse should focus on which of the following areas? a) Reduction of bodily tensions and stress management. b) Analysis of fears and barriers to growth. c) Substitution of rational beliefs for self-defeating thinking and behaving. d) Insight into unconscious conflicts and processes. - Substitution of rational beliefs for self-defeating thinking and behaving. Explanation: Substituting rational beliefs is a major goal when using cognitive-behavioral models, which focus more on thinking and behaviors than feelings. Unconscious processes are the focus of psychoanalytic models. Analysis of fears and barriers to growth are the focus of developmental models. Tension and stress are targets of the stress models.