NCLEX RN NURSING 102 FINAL EXAM

NCLEX RN NURSING 102 FINAL EXAM

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

• Orient the client to his room
• Conduct a client care conference
• Review medical prescriptions
• Develop a plan of care Answer - A. Orient the client to his room

*The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at bedside.*

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family?

• Body mass index
• Usual times for meals and snacks
• Favorite foods
• Any difficulty swallowing Answer - D. Any difficulty swallowing

*The greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life- threatening.*

A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention?

• Measure vital signs
• Encourage HIV screening
• Determine risk factors
• Instruct the client to use condoms Answer - C. Determine risk factors

*The first action the nurse should take using the nursing process is assessment. The nurse should talk with the client first to determine which risk factors the client might have before initiating the appropriate health promotion and disease prevention measures.*

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply)

• Help the client see the benefits of their actions
• Identify the client's support systems
• Suggest and recommend community resources
• Devise and set goals for the client
• Teach stress management strategies Answer - A. B. C. E.

*The nurse should assist the client to recognize the benefits of her health promoting actions while also overcoming barriers to implementing actions.

The nurse should collect information about who can help the client change unhealthful behaviors, and then suggest steps to have friends and family to become involved and supportive.

The nurse should promote the client's use of any available community or online resources that can help the client progress toward meeting set goals.

The nurse should teach that stress is a contributing factor to CVD, as well as many other specific and systemic disorders.*

A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client?

• Testicular examination
• Blood glucose
• Fecal Occult Blood
• Prostate-Specific Antigen Answer - A. Testicular examination

*Starting at age 20, the client should have examinations for testicular cancer, along with blood pressure and body mass index measurements and cholesterol determinations.*

A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention?

• Cholesterol screening
• Nutrition presentation
• Medication therapy

• Cardiac Rehabilitation Answer - B. Nutrition Presentation

*Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness.*

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?

• "So I don't need the colon cancer procedure for another 2 to 3 years"
• "For now, I should continue to have a mammogram each year."
• "Because the doctor just did a Pap Smear, I'll come back next year for another one."
• "I had my blood glucose test last year, so I won't need it again till next year."

Answer - B. "For now, I should continue to have a mammogram each year."

*The female client who is between ages of 40 and 50 should have a mammogram annually.*

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

• The client is able to discuss the appropriate technique
• The client is able to demonstrate the appropriate technique
• The client states that he understands
• The client is able to write the steps on a piece of paper Answer - B. The client is

able to demonstrate the appropriate technique

*Demonstrating the appropriate technique indicates the psychomotor learning has taken place.*

A nurse in a provider's office is collecting data from the mother of a 12-month-old-infant.The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains?

• Cognitive
• Affective
• Psychomotor
• Kinesthetic Answer - B. Affective

*Affective learning has taken place because the client's ideas about toilet training changed.*

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• "I don't want my spouse to see my incision."
• "Will toy give me pain medicine after the surgery?"
• "Can you tell me about how long the surgery will take?"
• "My roommate listens to everything I say" Answer - C. "Can you tell me about how

long the surgery will take?"

*Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer can cause anxiety, fear, or depression, all of which can interfere with the learning process.*

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client?

• Encourage the client to participate actively in learning
• Select instructional materials appropriate for the older adult
• Identify goals the nurse and the client agree are reasonable
• Determine what the client knows about stress incontinence Answer - D. Determine

what the client knows about stress incontinence

*The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this problem before instructing the client.*

A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning?

• Encourage the client to ask questions
• Ask the client to explain how to select or prepare meals
• Encourage the client to fill out an evaluation form
• Ask the client if she has resources for further instruction on this topic Answer - B.

Ask the client to explain how to select or prepare meals

*A useful strategy for evaluating learning is to ask the client to explain in her own words how she will implement what she learned.*

A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next?