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2933 soru

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Soru 1781Soru →

An older adult client with Alzheimer's disease is admitted to a medical-surgical unit for treatment of a urinary tract infection. In the late afternoon, the client becomes increasingly restless, paces the hallway, and repeatedly attempts to leave the unit, stating, "I need to catch the bus to pick up my children." Which of the following interventions should the practical nurse (PN) implement? Select all that apply.

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Cevap: Walk alongside the client while asking open-ended questions about their children.; Provide the client with a safe, repetitive motor task, such as folding washcloths.; Maintain a well-lit, clutter-free environment in the areas where the client is pacing.

Cevap

The correct interventions are to walk alongside the client while asking about their children, provide a safe repetitive motor task, and maintain a well-lit, clutter-free environment.
For an agitated client with dementia, the least restrictive non-pharmacological interventions must be utilized first. Pacing alongside the client prevents physical confrontation and promotes a calming presence. Using validation therapy by asking about their children addresses their underlying anxiety without sparking an argument. Providing a simple, repetitive task like folding washcloths redirects their energy into a safe, purposeful activity. Finally, maintaining a clutter-free and well-lit environment ensures the client's physical safety while they are wandering.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and identify the underlying behavioral issue.
The client has Alzheimer's disease and an active infection (UTI), and is exhibiting sundowning behaviors with psychomotor agitation (pacing, trying to leave).
Understanding the underlying cause of the behavior helps the nurse select the appropriate, least restrictive intervention.
2
Evaluate each potential intervention against the least-restrictive hierarchy.
Physical restraints and arguing with the client must be avoided. Validation, redirection, and environmental safety are prioritized.
The PN must use the least invasive non-pharmacological methods to de-escalate the behavior, respect client autonomy, and ensure safety.
3
Select all interventions that promote safety and utilize therapeutic communication.
Walking with the client, offering a repetitive task, and clearing the hallway are the correct actions.
These choices align with behavioral management best practices for dementia clients.

Anahtar Kavram

Non-Pharmacological Behavioral Interventions for Dementia
Soru 1782Soru →

A practical nurse is caring for a client who is recovering from a recent myocardial infarction. When the nurse encourages the client to ambulate, the client states, "I am terrified to even walk to the bathroom. What if my heart just stops?" Which of the following responses by the nurse are therapeutic? Select all that apply.

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Cevap: It sounds like you are very frightened about what might happen when you exert yourself.; Can you tell me more about the thoughts you have when you think about getting out of bed?

Cevap

The therapeutic responses are those that reflect the client's feelings and explore their concerns through open-ended questioning.
The correct responses utilize reflection ('It sounds like you are very frightened...') and exploration ('Can you tell me more...'). These techniques validate the client's intense fear and encourage them to continue sharing their concerns, which builds trust and facilitates emotional processing.

Adım Adım Çözüm

1
Analyze the client's statement to identify their core emotion.
The client is expressing severe anxiety and fear ('terrified') about physical activity and the possibility of a recurrent cardiac event.
Understanding the client's emotional state is necessary to select a response that validates their feelings rather than dismissing them.
2
Evaluate each nursing response for therapeutic communication techniques.
Responses that use reflection and open-ended exploration are therapeutic. Responses that offer false reassurance or ask 'why' are communication blocks.
Therapeutic communication should encourage the client to express feelings and feel understood, whereas non-therapeutic blocks shut down communication or create defensiveness.

Anahtar Kavram

Therapeutic Communication vs. Non-therapeutic Blocks
Soru 1783Soru →

A practical nurse is positioning a client in bed shortly after a thyroidectomy. Which of the following positions should the nurse use to promote client comfort and reduce the risk of complications?

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Cevap: Semi-Fowler's position with pillows supporting the head and neck

Cevap

The most appropriate position is the semi-Fowler's position with pillows supporting the head and neck.
The semi-Fowler's position elevates the head, which utilizes gravity to help decrease surgical edema in the neck and facilitates easier breathing. Supporting the head and neck with pillows maintains neutral alignment, preventing tension on the suture line and reducing pain.

Adım Adım Çözüm

1
Identify the surgical procedure and its anatomical location.
The client had a thyroidectomy, which involves an incision in the anterior neck.
Understanding the surgical site highlights the specific risks, primarily airway compromise from tissue edema and tension on the suture line.
2
Determine the physiological goal of postoperative positioning for this specific surgery.
The goal is to minimize swelling (edema) in the neck and protect the surgical incision from stretching.
Swelling in the neck can quickly lead to respiratory distress, and stretching the neck can tear the sutures.
3
Select the position that best achieves these goals.
Semi-Fowler's position uses gravity to reduce swelling, and supporting the head with pillows keeps the neck in a neutral position to avoid tension.
This combination effectively addresses the primary postoperative risks for neck surgery.

Anahtar Kavram

Postoperative Care and Positioning
Soru 1784Soru →

A client is recovering from a complicated urinary tract infection in a subacute care facility. The client has a history of post-traumatic stress disorder (PTSD). At 0300, the practical nurse (PN) enters the dimly lit room and observes the client backed against the wall, trembling, pointing at a coat rack, and yelling that an attacker is standing there. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Turn on the overhead lights, maintain a safe distance, and calmly reassure the client of their immediate safety.

Cevap

The correct action is to turn on the overhead lights, maintain a safe distance, and calmly reassure the client of their immediate safety.
The client is experiencing a severe fear response, likely triggered by a visual illusion (misinterpreting the shadowed coat rack) secondary to acute delirium from the infection and exacerbated by a PTSD history. The priority is ensuring safety through the least restrictive means. Turning on the lights alters the sensory environment to eliminate the visual trigger, while maintaining distance and offering calm reassurance provides therapeutic de-escalation without provoking a physical altercation.

Adım Adım Çözüm

1
Analyze the clinical presentation.
The client is experiencing a sudden onset of severe fear and visual misinterpretation (illusion/hallucination) in the context of an active infection (UTI) and a dimly lit environment.
Identifying the nature of the crisis determines the priority intervention.
2
Differentiate the underlying physiological and psychological factors.
The acute presentation points to delirium (secondary to infection) complicated by PTSD trauma responses, rather than a permanent cognitive decline like dementia.
Accurate clinical recognition prevents inappropriate documentation and guides safe, immediate care.
3
Select the safest, least restrictive intervention.
Turning on the lights alters the sensory environment to eliminate the visual trigger (the shadowed coat rack).
Environmental modification must precede chemical or physical restraints, and maintaining distance ensures staff safety during a psychological crisis.

Anahtar Kavram

Crisis De-escalation and Delirium Recognition
Soru 1785Soru →

During a medication administration round, a client recently diagnosed with Huntington's disease states to the practical nurse, 'I do not know how I am going to tell my teenage children about this. It feels like I am handing them a death sentence.' Which response by the nurse is the most therapeutic?

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Cevap: You are experiencing a great deal of anxiety about how this illness will affect your children.

Cevap

The most therapeutic response is to reflect the client's feelings by stating that they are experiencing a great deal of anxiety about how the illness will affect their children.
The correct answer utilizes reflection, a therapeutic technique that directs the client's ideas, feelings, and questions back to them. By acknowledging the heavy anxiety the client feels regarding their children, the nurse validates the client's emotional experience and creates a safe, non-judgmental space for the client to explore these fears further.

Adım Adım Çözüm

1
Analyze the client's statement to identify the core emotion.
The client is expressing profound fear, guilt, and feeling overwhelmed by the prospect of disclosing a genetic, life-limiting diagnosis to their children.
Identifying the underlying emotion is the first step in selecting a therapeutic communication technique.
2
Evaluate the nursing responses for therapeutic vs. non-therapeutic techniques.
Reflecting the client's anxiety validates their emotional state. Giving advice, normalizing/minimizing, and asking closed-ended leading questions are non-therapeutic.
Therapeutic communication should remain client-centered, encourage verbalization of feelings, and avoid imposing the nurse's values or assumptions.
3
Select the option that best facilitates continued dialogue.
The reflective statement acknowledges the client's burden without offering false hope or premature solutions.
Reflection demonstrates empathy and invites the client to elaborate on their feelings at their own pace.

Anahtar Kavram

Therapeutic Communication Techniques: Reflection and Validation
Soru 1786Soru →

A practical nurse (PN) is gathering focused physical data on an older adult client who was just admitted to the medical-surgical unit with a suspected respiratory infection. Which of the following actions by the PN are appropriate? Select all that apply.

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Cevap: Auscultating the anterior, posterior, and lateral lung fields systematically; Inspecting the client's oral mucous membranes, nail beds, and skin color for cyanosis; Verifying the client's apical pulse for one full minute using a stethoscope

Cevap

The correct actions include auscultating the lung fields systematically, inspecting for cyanosis, and verifying the apical pulse for one full minute.
The appropriate data collection actions within the PN scope of practice include systematically auscultating all lung fields to detect abnormal breath sounds, inspecting mucous membranes and skin for cyanosis (which indicates hypoxia), and obtaining an accurate apical pulse for one full minute to assess cardiovascular function. These focused data collection techniques provide vital baseline information to share with the supervising RN or healthcare provider.

Adım Adım Çözüm

1
Identify the role and scope of the practical nurse (PN) in data collection.
The PN performs focused physical observations and gathers objective baseline data to report to the RN or provider.
The PN contributes to the assessment process but does not independently diagnose or formulate the initial comprehensive plan of care.
2
Evaluate each action for clinical appropriateness in the context of an older adult with a respiratory infection.
Auscultating lung fields, inspecting for cyanosis, and taking a full-minute apical pulse are all appropriate, within-scope data collection techniques.
These techniques yield objective data essential for monitoring the client's respiratory and cardiovascular status.
3
Identify actions that represent clinical errors or out-of-scope practices.
Assuming new confusion is normal aging, making independent nursing diagnoses, and failing to report borderline vital signs are incorrect.
Acute confusion is a sign of delirium or hypoxia, diagnosis is an RN responsibility, and abnormal vitals require immediate escalation.

Anahtar Kavram

Data Collection Techniques within PN Scope of Practice
Soru 1787Soru →

A practical nurse is assisting with the care of a client who was recently diagnosed with an advanced, incurable illness. The client spends hours each day researching experimental trials online, organizing a meticulous binder of laboratory values, and discussing the pathophysiology of the disease with the nursing staff in a detached, emotionless manner. Based on the client's behavior, which of the following is the most appropriate action by the practical nurse?

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Cevap: Support the client's information-gathering behavior while remaining consistently available for emotional support when the client is ready.

Cevap

The most appropriate action is to support the client's information-gathering behavior while remaining consistently available for emotional support when the client is ready.
The client is demonstrating intellectualization, an ego defense mechanism where emotional responses to a profound stressor are temporarily avoided by focusing exclusively on logic, facts, and cognitive data. Because defense mechanisms serve to protect the client from overwhelming anxiety, the practical nurse should not attempt to forcefully remove or confront them unless they pose a direct safety risk. The most therapeutic approach is to respect the client's current coping strategy while maintaining an open, supportive presence so the client feels safe expressing underlying emotions when they are eventually ready.

Adım Adım Çözüm

1
Analyze the client's behavioral response to the diagnosis.
The client is focusing entirely on facts, data, and research in an emotionless manner.
Identifying the specific behavior is necessary to determine the underlying coping mechanism.
2
Identify the defense mechanism being utilized.
The behavior is a classic presentation of intellectualization.
Intellectualization involves separating emotions from a stressful event by focusing on logic and facts to reduce immediate anxiety.
3
Determine the appropriate nursing intervention for this specific coping mechanism.
The nurse should allow the behavior to continue while providing a supportive presence.
Unless a defense mechanism is actively causing harm, it should not be dismantled abruptly, as it is currently protecting the client from overwhelming psychological distress.

Anahtar Kavram

Defense Mechanisms: Intellectualization and Therapeutic Communication
Soru 1788Soru →

A practical nurse (PN) is providing care for a veteran who recently underwent orthopedic surgery and has a documented history of post-traumatic stress disorder (PTSD). The client abruptly awakens, begins shouting commands as if in a combat zone, and forcefully throws their bedside table. Arrange the following actions the PN should take in the correct chronological order of priority.

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Cevap

The correct sequence prioritizes immediate physical safety, followed by environmental control, verbal de-escalation, physiological assessment, and finally, interdisciplinary communication.
In any psychiatric emergency, crisis intervention guidelines dictate that safety is the absolute priority. The nurse must first secure their own safety by maintaining an exit path, then protect others by clearing the room. After the environment is secure, least-restrictive interventions like verbal de-escalation are applied. Only when the client is calm can physical data collection occur safely, followed by documentation and reporting to the interdisciplinary team.

Adım Adım Çözüm

1
Secure personal safety
The nurse has a clear path to escape if the client becomes physically violent.
A healthcare provider cannot safely assist a client if the provider is injured or trapped in a confined space.
2
Protect bystanders and reduce stimuli
Visitors and extra staff are removed from the room.
This protects others from potential harm and decreases the sensory input that may be exacerbating the client's PTSD flashback.
3
Initiate verbal de-escalation
The client is oriented to reality using a calm, non-threatening approach.
Once the environment is safe, therapeutic communication is the least restrictive method to help the client regain emotional control.
4
Perform physiological data collection
Vital signs and oxygen saturation are obtained after the client is calm.
Sudden confusion or severe agitation can be triggered by hypoxia, infection, or severe pain, which must be evaluated once it is physically safe to do so.
5
Communicate with the healthcare team
The charge nurse is informed of the event.
Reporting allows the team to evaluate the need for medication adjustments or changes to the collaborative care plan.

Anahtar Kavram

Prioritization in Psychiatric Emergencies (Safety, De-escalation, Assessment, Reporting)
Tahmini Süre:1m 30s
Soru 1789Soru →

A practical nurse (PN) is assigned to obtain orthostatic vital signs for a client who reports episodes of dizziness when getting out of bed. In what order should the PN perform the following data collection steps? Arrange the actions in the correct sequence.

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Cevap

The correct sequence is: 1) Have the client rest supine, 2) Measure baseline vitals, 3) Assist to sitting, 4) Wait 1-3 minutes and measure sitting vitals, 5) Assist to standing and measure standing vitals.
Obtaining orthostatic vital signs requires a specific, sequential approach to accurately capture how the cardiovascular system responds to gravity and position changes. The sequence begins by having the client rest supine for 5 to 10 minutes to establish a stable baseline, followed immediately by measuring the baseline blood pressure and pulse. Next, the client is assisted to a sitting position, and the nurse must wait 1 to 3 minutes to allow for physiologic compensation before taking the second set of measurements. Finally, the client is assisted to a standing position, and the third set of measurements is taken after an additional 1 to 3 minutes. This precise order ensures safety and data accuracy.

Adım Adım Çözüm

1
Establish a resting baseline.
The client rests supine for 5 to 10 minutes, after which initial vital signs are measured.
A stable physiological baseline is necessary to accurately compare against subsequent positional changes.
2
Assess the cardiovascular response to sitting.
The client sits on the edge of the bed and vitals are taken after a 1 to 3 minute delay.
Waiting allows adequate time for orthostatic hypotension to manifest before measuring.
3
Assess the cardiovascular response to standing.
The client stands and final vitals are measured after another 1 to 3 minute delay.
Standing is the most physiologically demanding position and completes the comprehensive orthostatic assessment.

Anahtar Kavram

Orthostatic Vital Sign Measurement
Soru 1790Soru →

The practical nurse (PN) is assigned to initiate intensive phototherapy in the postpartum unit for a 36-hour-old neonate, born at 38 weeks of gestation, who has been diagnosed with severe hyperbilirubinemia. Arrange the following nursing actions in the correct chronological sequence to safely and effectively implement this therapy.

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Cevap

The correct sequence is to first verify the prescription and identity, then undress the neonate, apply the protective eye shields, position the neonate and adjust the lights, and finally activate the unit, measure the irradiance, and report to the RN.
The correct sequence prioritizes client safety and therapeutic efficacy. Verification of the prescription and identity is always the first action. Next, undressing the infant prepares them for maximum skin exposure, which is necessary for effective bilirubin breakdown. Crucially, the opaque eye shields must be applied before the lights are turned on to prevent retinal damage. Proper positioning of the infant and equipment ensures the light covers the target area without causing thermal harm. Finally, turning the lights on, measuring irradiance at the skin level, and reporting the data to the RN confirms the delivery of the prescribed therapeutic dose and adheres to the PN scope of practice.

Adım Adım Çözüm

1
Verify prescription and neonate identity.
Ensures correct treatment for the correct client.
Patient safety standards mandate verification before any intervention.
2
Undress the neonate, leaving only a diaper.
Maximizes the skin surface area.
Phototherapy is most effective when the maximum amount of skin is exposed to the light.
3
Close eyelids and apply opaque eye shields.
Protects the infant's retinas.
Intense phototherapy lights can cause irreversible ocular damage if the eyes are unprotected.
4
Position the neonate and adjust the light source distance.
Sets up the physical treatment environment.
Correct positioning ensures optimal light distribution and prevents thermal injury.
5
Activate the unit, measure irradiance, and report to the RN.
Initiates therapy and maintains collaborative communication.
Irradiance must be measured to verify therapeutic dose, and the PN must report findings to the supervising RN.

Anahtar Kavram

Safe initiation sequence for neonatal phototherapy within the PN scope of practice
Soru 1791Soru →

A practical nurse is preparing to administer a scheduled oral antibiotic to a client. The barcode on the client's identification band is smudged and cannot be scanned by the medication administration system. The client is alert and oriented. Which action should the nurse take next?

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Cevap: Request a new identification band, verify the client's identity using two identifiers, and then administer the medication.

Cevap

The nurse should request a new identification band, verify the client using two identifiers, and then administer the medication.
Safe medication administration requires the nurse to verify the client's identity using two distinct identifiers (such as name and date of birth) and to scan the client's physical identification band. If the band is unreadable, a new one must be obtained and placed on the client prior to administration to ensure strict compliance with medication safety protocols.

Adım Adım Çözüm

1
Identify that the current identification band is unreadable.
The nurse recognizes a barrier to safe medication administration.
A readable barcode is required for the electronic safety check.
2
Obtain a new identification band for the client.
A functional barcode is made available for scanning.
The system requires a barcode attached directly to the client to verify they are the right person.
3
Verify the client's identity using two distinct identifiers and scan the new band.
The client's identity is safely and accurately confirmed.
Using two identifiers fulfills the 'right client' requirement of safe medication administration.

Anahtar Kavram

Medication Rights Verification
Soru 1792Soru →

An LPN/LVN on a medical-surgical oncology unit is assisting with the care of a client who is in the final days of life. The client is exhibiting signs of terminal restlessness and agitation, which is causing visible distress to the visiting family members. Which actions should the nurse implement to promote comfort and provide psychosocial support? Select all that apply.

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Cevap: Dim the lights in the room and minimize extraneous environmental noise.; Inform the family that periods of restlessness and agitation are a normal part of the dying process.; Play soft, familiar music if the family indicates it previously brought the client comfort.

Cevap

The correct actions are to dim the lights and minimize noise, inform the family that restlessness is a normal part of the dying process, and play soft, familiar music if it brings comfort.
Appropriate end-of-life care for a restless client involves modifying the environment to reduce sensory overload (dimming lights, reducing noise) and implementing familiar, soothing interventions like soft music. Additionally, the nurse provides vital psychosocial support by explaining to the family that terminal restlessness is a normal physiological change during the dying process, which helps validate their concerns and reduce their fear.

Adım Adım Çözüm

1
Identify the primary clinical issue and the goal of care.
The client is experiencing terminal restlessness, and the family is highly distressed. The goal is palliative comfort and psychosocial support.
Understanding that the client is in the final days of life shifts the focus from acute medical interventions to symptom management and holistic comfort.
2
Evaluate the physical comfort interventions proposed in the options.
Dimming lights, reducing noise, and playing familiar music are appropriate non-pharmacological comfort measures. Restraints are inappropriate.
Environmental modifications promote a peaceful atmosphere, whereas physical restraints bypass less restrictive alternatives and typically increase agitation.
3
Evaluate the psychosocial and communication interventions proposed.
Explaining the normalcy of the symptoms is highly supportive. Promising the client will reach 'acceptance' and asking 'why' questions are non-therapeutic.
Therapeutic communication validates the family's experience and provides factual, comforting information without relying on rigid grief stages or communication blocks.

Anahtar Kavram

Terminal Restlessness and Palliative Comfort Measures
Soru 1793Soru →

A 79-year-old client is admitted to the medical unit with new-onset severe confusion and a temperature of 102.4∘F102.4^\circ\text{F} (39.1∘C39.1^\circ\text{C}). The client's medication orders include a stat intravenous (IV) push antibiotic and a routine intramuscular influenza vaccine. The registered nurse delegates the administration of both medications to the practical nurse. Which action is most appropriate for the practical nurse to take?

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Cevap: Refuse the delegation for the IV push antibiotic due to scope limitations, and withhold the influenza vaccine because of the acute febrile illness, reporting to the registered nurse.

Cevap

The practical nurse should decline the IV push medication because it is outside their scope of practice, and withhold the influenza vaccine because the client is currently experiencing a severe acute febrile illness.
The correct action requires the practical nurse to recognize two distinct safety issues. First, the administration of IV push medications generally falls outside the scope of practice for a practical nurse, as it requires advanced assessment and clinical judgment during rapid drug delivery. Second, the client's high fever and sudden confusion indicate an acute, moderate-to-severe illness, which is a recognized clinical precaution for withholding the influenza vaccine until the acute phase resolves.

Adım Adım Çözüm

1
Analyze the delegated IV push antibiotic administration against the practical nurse scope of practice.
Determine that administering medications via IV push involves a level of assessment and clinical judgment reserved for registered nurses.
Ensuring safe and legal delegation is a continuous responsibility of the practical nurse.
2
Evaluate the client's current clinical presentation regarding the ordered influenza vaccine.
Identify that the client has a high fever of 102.4∘F102.4^\circ\text{F} (39.1∘C39.1^\circ\text{C}) and new-onset confusion.
Moderate to severe acute illness, with or without a fever, is a standard precaution indicating that a vaccine should be deferred until the illness resolves.
3
Formulate the safest evidence-based response.
Refuse the IV push assignment, hold the influenza vaccine, and immediately notify the registered nurse of these decisions.
This protects client safety, prevents medication errors, and keeps the nurse within their legal scope of practice.

Anahtar Kavram

Scope of Practice and Immunization Contraindications
Soru 1794Soru →

A practical nurse (PN) is assigned to assist with a client who arrived at the emergency department covered in a toxic liquid agricultural pesticide. Which actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Put on a fluid-resistant gown, gloves, and face shield prior to client contact.; Remove the client's contaminated clothing and seal it in a designated hazardous materials bag.; Irrigate the client's exposed skin thoroughly with copious amounts of water.

Cevap

The practical nurse should put on appropriate personal protective equipment before contact, safely remove and seal the client's contaminated clothing, and thoroughly irrigate the client's skin with water.
Initial management of a hazardous chemical exposure requires prioritizing staff safety by donning appropriate protective equipment prior to contact. The client must then be rapidly decontaminated by removing saturated clothing—which must be sealed to contain toxic fumes—and washing the skin with copious amounts of water to dilute and remove the chemical.

Adım Adım Çözüm

1
Identify the hazard and required safety precautions.
The nurse dons a gown, gloves, and face shield.
Protects the healthcare worker from direct contact and secondary exposure to the pesticide.
2
Perform immediate physical decontamination of the client.
Contaminated clothing is removed and sealed, and the skin is flushed with water.
Halts ongoing chemical absorption and contains the hazardous material safely.
3
Recognize scope of practice boundaries.
The IV push medication task is deferred to the registered nurse (RN).
Intravenous push administration exceeds the standard scope of practice for practical nursing.

Anahtar Kavram

Hazardous Material Decontamination and Scope of Practice
Soru 1795Soru →

A practical nurse (PN) enters a client's room and observes the client attempting to light a cigarette while receiving continuous oxygen therapy via a nasal cannula. In what order should the PN perform the following actions? (Arrange the actions in the correct sequence, from first to last.)

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Cevap

The correct sequence of actions is: 1) Turn off the oxygen and confiscate the smoking materials, 2) Obtain vital signs and oxygen saturation, 3) Notify the charge nurse, 4) Reinforce teaching regarding fire hazards, and 5) Document the incident.
In any clinical scenario involving high-risk behavior that poses an immediate threat to life, the absolute first priority is risk reduction and safety. Because oxygen supports combustion, smoking in its presence is a catastrophic fire hazard; thus, stopping the oxygen and removing the cigarette is the priority. Second, because therapy was interrupted, the PN must assess the client's respiratory status. Third, the PN must report this critical event to the charge nurse so the interdisciplinary team can manage the client's care. Fourth, the PN reinforces education to prevent a recurrence. Finally, the PN documents the entire event chronologically.

Adım Adım Çözüm

1
Eliminate the immediate environmental hazard.
The oxygen flowmeter is turned off and the ignition source is removed.
Fire risk in an oxygen-rich environment presents an immediate, lethal threat to the client, staff, and facility. Emergency safety supersedes all other nursing actions.
2
Assess the client's physiological response.
Oxygen saturation and respiratory rate are obtained.
Because a prescribed respiratory treatment was abruptly stopped, the PN must determine if the client is experiencing hypoxia or respiratory distress.
3
Report the incident to the supervising nurse.
The charge nurse is informed of the high-risk behavior and interrupted therapy.
The RN must be informed of the change in condition and safety breach to coordinate further medical or behavioral interventions.
4
Reinforce safety education.
The client receives education on the dangers of oxygen combustion.
Targeted education addresses the high-risk behavior and aims to prevent future, potentially fatal non-compliance.
5
Document the event.
The incident is recorded in the medical record.
Accurate charting provides a legal record of the event, the nursing actions taken to protect the client, and the client's subsequent status.

Anahtar Kavram

Prioritization of safety and risk reduction during acute high-risk behavioral incidents.
Soru 1796Soru →

While working in an acute mental health facility, a practical nurse observes a client with schizophrenia pacing the main corridor. The client has clenched fists, is breathing rapidly, and is glaring at a nearby staff member. Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Maintain a safe distance, use a calm voice, and invite the client to walk to a quieter area.

Cevap

The nurse should prioritize safety and least-restrictive interventions by maintaining a safe distance and using verbal de-escalation to guide the client to a lower-stimulus environment.
The client is demonstrating early signs of agitation and potential escalation. The priority action is to employ verbal de-escalation techniques while ensuring physical safety. Maintaining a safe distance prevents the client from feeling trapped, and offering a quieter area reduces environmental stimulation. This approach aligns with the principle of using the least-restrictive intervention first.

Adım Adım Çözüm

1
Assess the client's current behavioral state based on physical cues.
The nurse identifies that pacing, clenched fists, and glaring indicate escalating agitation and a potential behavioral crisis.
Early recognition of agitation allows for prompt intervention before physical violence occurs.
2
Determine the safest physical positioning for the nurse.
The nurse decides to maintain a safe distance rather than physically confronting or blocking the client.
Invading personal space or attempting to physically block an agitated client increases the immediate risk of assault.
3
Select the appropriate de-escalation technique following the least-restrictive hierarchy.
The nurse uses a calm, non-confrontational voice to invite the client to a quieter area.
Verbal de-escalation and environmental modification (moving to a quieter area) are the least restrictive initial interventions for an escalating client.

Anahtar Kavram

Behavioral Interventions and De-escalation
Soru 1797Soru →

An assessment is being performed by the practical nurse on a multiparous client who delivered a macrosomic neonate precipitously three hours ago. The client states, "I feel very thirsty and I just cannot get comfortable." The current vital signs reveal a heart rate of 118 beats/min, respirations of 24 breaths/min, and blood pressure of 102/68 mmHg. Palpation of the abdomen reveals a firm, midline uterine fundus at the level of the umbilicus. Inspection of the perineum shows a steady, continuous trickle of bright red blood. What is the priority nursing action?

Cevabı ve açıklamayı göster

Cevap: Report the clinical findings to the supervising registered nurse immediately.

Cevap

Report the clinical findings to the supervising registered nurse immediately.
The correct answer addresses the urgent need for medical evaluation based on signs of hypovolemic shock and bleeding from a suspected laceration. Because the fundus is already firm, nursing interventions for atony (like massage) are not indicated. The practical nurse must recognize the critical nature of a steady trickle of blood combined with tachycardia and thirst, and immediately escalate the situation to the registered nurse or healthcare provider to prevent severe hemodynamic collapse.

Adım Adım Çözüm

1
Analyze the client's vital signs and subjective symptoms.
The client has tachycardia (118 beats/min), tachypnea (24 breaths/min), thirst, and restlessness, which are early compensatory signs of hypovolemic shock.
Recognizing early physiological deterioration is essential for timely intervention before severe hypotension occurs.
2
Evaluate the uterine fundus and lochia characteristics.
The fundus is firm and midline, but there is a continuous trickle of bright red blood.
A firm fundus rules out uterine atony as the source of bleeding. A continuous trickle of blood with a firm fundus points directly to trauma, such as a vaginal or cervical laceration from the precipitous birth of a macrosomic infant.
3
Determine the practical nurse's scope of practice.
Diagnosing a laceration and ordering advanced interventions (like surgical repair or massive blood transfusion) are outside the PN scope.
The PN must recognize the critical deviation from normal and immediately escalate the findings to the RN or healthcare provider.

Anahtar Kavram

Postpartum Hemorrhage Assessment and Scope of Practice
Soru 1798Soru →

An unresponsive client with terminal heart failure resides in a long-term care facility under a comfort-measures-only plan. The client begins exhibiting alternating periods of deep, rapid breathing and brief apnea. The client's distressed spouse intercepts the licensed practical nurse in the hallway, stating, 'My husband can't catch his breath! You have to call 911 and get him on a ventilator immediately!' Which is the priority therapeutic response by the nurse?

Cevabı ve açıklamayı göster

Cevap: "It must be very frightening to see him breathe this way. These breathing changes are an expected part of the body's natural dying process."

Cevap

The nurse should validate the spouse's feelings by stating that it must be frightening to witness, and then explain that these breathing changes are an expected part of the natural dying process.
The correct response utilizes the therapeutic techniques of validation and information giving. It addresses the spouse's immediate emotional distress by acknowledging how frightening the situation is, while simultaneously providing essential education that Cheyne-Stokes respirations (deep breathing followed by periods of apnea) are a normal, expected part of the dying process. This helps de-escalate the panic without resorting to non-therapeutic communication blocks or inappropriate medical interventions.

Adım Adım Çözüm

1
Analyze the clinical scenario and the client's status.
The client is unresponsive, actively dying on comfort measures, and experiencing Cheyne-Stokes respirations, which is a normal end-of-life finding.
Accurate clinical assessment prevents the nurse from initiating inappropriate emergency interventions for expected terminal symptoms.
2
Evaluate the spouse's statement and emotional state.
The spouse is experiencing acute distress, fear, and a misunderstanding of the client's symptoms, prompting a demand for aggressive interventions.
Identifying the psychosocial crisis determines the need for therapeutic communication.
3
Select the response that best combines empathy with appropriate education.
The optimal response validates the spouse's fear ("It must be very frightening...") and gently corrects the misunderstanding without being confrontational or overly clinical.
Therapeutic communication requires addressing both the emotional component and the knowledge deficit to effectively support a grieving family member.

Anahtar Kavram

Therapeutic Communication and Symptom Management at End of Life
Soru 1799Soru →

A client admitted with a severe traumatic brain injury is exhibiting signs of increased intracranial pressure (ICP) and is currently receiving mechanical ventilation. The practical nurse (PN) observes that the client has had a large incontinent liquid bowel movement and requires immediate perineal hygiene and a bed linen change. Which action by the PN demonstrates the most appropriate integration of basic comfort care and physiological safety for this client?

Cevabı ve açıklamayı göster

Cevap: Maintaining the client's head and neck in a neutral, midline alignment while gently logrolling the body to the side.

Cevap

Maintaining the client's head and neck in a neutral, midline alignment while gently logrolling the body to the side.
When providing basic hygiene and comfort care to a client with increased intracranial pressure, the nurse must prevent activities that impede cerebral venous return. Maintaining the head and neck in a neutral, midline position prevents kinking or compression of the jugular veins. Logrolling ensures the neck does not twist during turning. Together, these actions allow the nurse to clean the client and change the linens without causing a dangerous spike in intracranial pressure.

Adım Adım Çözüm

1
Analyze the client's primary pathophysiological risk.
The client has increased intracranial pressure (ICP), which can be fatally exacerbated by improper positioning or excessive stimulation.
Identifying the critical physiological constraint determines how basic care must be modified.
2
Evaluate the impact of neck and body alignment on cerebral hemodynamics.
Neck flexion, extension, or rotation compresses the jugular veins, trapping blood in the cranium and increasing ICP.
The jugular veins are the primary pathway for cerebral venous drainage.
3
Select the hygiene technique that minimizes physiological stress.
Logrolling keeps the spine, neck, and head aligned as a single unit, preventing cervical twisting while allowing access to the perineum and back.
This method safely accomplishes the basic care requirement without compromising neurological stability.

Anahtar Kavram

Modification of basic care and positioning to prevent elevation of intracranial pressure
Soru 1800Soru →

During a multidisciplinary care conference at a substance use rehabilitation center, a practical nurse reviews notes regarding the family dynamics of a newly admitted client. Pair the documented observations of the family members with the specific psychological defense mechanism being demonstrated.

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Öğeler

The spouse, who harbors deep resentment about the addiction, becomes overly devoted and constantly praises the client's 'flawless' character during group sessions.
After a heated argument with the client about finances, the sibling purchases an expensive watch for the client the next day without addressing the conflict.
The parent channels severe anxiety about the client's potential relapse by organizing a highly successful, state-wide fundraising campaign for addiction awareness.
The adult child, who is furious at the client for missing graduation, harshly criticizes the clinic's receptionist for a minor scheduling delay.

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The observations match as follows: the spouse's excessive devotion represents reaction formation, the sibling's expensive gift represents undoing, the parent's fundraising represents sublimation, and the adult child's outburst at the receptionist represents displacement.
Each observation perfectly illustrates a classic ego defense mechanism used to cope with the stress of addiction in the family system. Reaction formation masks unacceptable resentment with exaggerated praise. Undoing attempts to erase the conflict of the argument through a symbolic gift. Sublimation turns the negative energy of anxiety into a constructive charitable effort. Displacement redirects the anger meant for the parent onto a safer, uninvolved target.

Adım Adım Çözüm

1
Analyze the spouse's behavior of acting outwardly devoted while secretly harboring resentment.
This maps to Reaction formation.
Reaction formation involves masking unacceptable true feelings by adopting and exhibiting the exact opposite attitudes or behaviors.
2
Evaluate the sibling purchasing an expensive gift immediately following a severe argument.
This maps to Undoing.
Undoing is an ego defense mechanism where a person tries to 'undo' an unhealthy, destructive, or threatening thought or action by engaging in contrary behavior.
3
Assess the parent directing their severe anxiety into a state-wide fundraising campaign.
This maps to Sublimation.
Sublimation represents an adaptive coping mechanism where negative or unacceptable impulses are transformed into socially productive and acceptable actions.
4
Examine the adult child directing intense anger toward the clinic receptionist instead of the client.
This maps to Displacement.
Displacement redirects strong, often negative, emotions from a primary source to a secondary, less intimidating target to avoid the repercussions of confronting the primary source.

Anahtar Kavram

Advanced Defense Mechanisms
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Tüm alıştırma soruları — NCLEX-PN | Examkin