NCLEX-RN clinical judgment practice questions set 7

Correct answer:

The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.

Correct answer:

The correct answer is to ask the client if he has noticed any bleeding or dark stools. Normal hemoglobin for males is 13.0 - 18 g/dl, and normal hematocrit for males is 42 - 52%. The values of hemoglobin and hematocrit provided for the client are below normal, indicating mild anemia. The first step for the nurse is to inquire about any signs of bleeding or changes in stools that could suggest bleeding from the gastrointestinal tract. This helps in assessing the possible cause of the low hemoglobin and hematocrit levels. The other options are not appropriate as calling 911 and going to the emergency department immediately is not warranted for mild anemia, scheduling a repeat test in 1 month delays addressing the current concern, and referring the client to a hematologist may be premature without investigating the cause of the low levels first.

Correct answer:

After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.

Correct answer:

When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.

Correct answer:

All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

Correct answer:

The correct answer is to instruct the patient to cough following bronchodilator utilization. In COPD and PVD patients, bronchodilators help to open up the airways, making coughing more effective in clearing secretions from the lungs. This instruction can aid in improving the patient's ability to breathe by enhancing airway clearance. Deep breathing techniques (Choice A) may help increase oxygen levels but may not directly address the patient's immediate concern of breathing difficulty. Coughing regularly and deeply (Choice B) can be beneficial, but the timing following bronchodilator use is more crucial to maximize its effectiveness. Decreasing CO2 levels by increasing oxygen intake during meals (Choice D) does not directly address the patient's concern about breathing ease or the role of bronchodilators in improving cough effectiveness.

Correct answer:

The correct action to help prevent a fire in a healthcare setting is to notify visitors or post signs indicating that oxygen is in use in certain areas. Oxygen is a combustible material, and awareness of its presence is crucial to prevent fire hazards. By informing all individuals in the facility about the use of oxygen through clear signs or notifications, the risk of improper use and potential fire accidents can be minimized. Choice A is incorrect because using an adaptor when plugging in client equipment is not directly related to fire prevention. Choice B is also incorrect as marking faulty equipment and using it until inspection does not directly address fire prevention. Choice D is not a recommended action for fire prevention; storing extra equipment with supplies does not address the specific fire risk associated with oxygen use.

Correct answer:

An assisted living facility is an example of a tertiary care provider. Tertiary care providers offer specialized services such as rehabilitation, long-term care, and management of complex medical conditions. These services are typically provided after primary and secondary care interventions. Choice A, primary care, focuses on preventive care and routine medical treatment for common illnesses, which is not the level of care provided by assisted living facilities. Choice B, secondary care, involves specialized medical services provided by medical specialists and hospitals for conditions that require a higher level of expertise than primary care, but it is not the level of care provided by assisted living facilities. Choice D, None of the above, is incorrect as assisted living facilities fall under the category of tertiary care providers.

Correct answer:

The correct answer is 'Depersonalization.' A nurse who distances themselves from clients to avoid emotional involvement is displaying depersonalization. This behavior is often seen in nurses experiencing burnout due to stress. Depersonalization can stem from low morale, moral distress, and may serve as a defense mechanism to cope with stress and emotional exhaustion. It is a way to shield oneself from feeling overwhelmed by the burdens of caring for others. Choice A, 'Objectivity,' is incorrect because objectivity involves maintaining a neutral and unbiased perspective, which is not the case here. Choice C, 'Procrastination,' is incorrect as it refers to delaying tasks, not emotional distancing. Choice D, 'Disruption,' is irrelevant to the scenario described and does not align with the nurse's behavior of detachment and lack of concern.

Correct answer:

The patient is exhibiting classic signs of diabetes, such as polydipsia (feeling very thirsty), polyuria (large amount of water intake and urinary frequency), and xerostomia (dryness of the mouth). These symptoms are indicative of high blood glucose levels, which are characteristic of diabetes. Other common signs of diabetes include poor vision, unexplained weight loss, peripheral neuropathy (tingling in the feet and hands), and fatigue. Angina is chest pain due to reduced blood flow to the heart, not associated with the symptoms described in the patient. Hypertension is high blood pressure, which typically does not present with these specific symptoms related to diabetes. Hypotension is low blood pressure and is not consistent with the signs and symptoms presented by the patient, pointing more towards diabetes as the likely diagnosis.