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NCLEX PRACTICE QUESTIONS with Rationale Answers. Bank Questions. Download to score A+

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1. The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing? A) Primary prevention B) Secondary pr... evention C) Tertiary prevention D) Quaternary prevention - Ans-Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza. 2. A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Quaternary prevention - Ans-Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration following the myocardial infarction. Tertiary-prevention activities are directed at rehabilitation rather than diagnosis and treatment. Care at this level aims to help patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning. 3. Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" A) "That's fine. Exercise is bad for you anyway." B) "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month." C) "I understand. Can you think of one reason why being more active would be helpful for you?" D) "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day." - Ans-The patient's response indicates that the patient is in the precontemplation stage and does not intend to change his behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with it. Asking an open-ended question may stimulate the patient to identify a reason to begin a behavior change. Nurses are challenged to motivate and facilitate change in health behavior when working with individuals. 4. A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? A) "Walking is OK. I really think running is better." B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good." - Ans-The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan. 5. A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) A) Difficulty paying his bills B) Seeing his pastor as a means of support C) Family practice of not routinely seeing a health care provider D) Stress from the divorce and the loss of a job - Ans-External factors impacting health practices include family beliefs and economic impact. How patients' families use health care services generally affects their health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. 6. The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? A) Physiological B) Safety and security C) Love and belonging D) Self-actualization - Ans-The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults. 7. When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? A) Holistic B) Health belief C) Transtheoretical D) Health promotion - Ans-The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care. 8. When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? A) Health belief B) Illness behavior C) Health promotion D) Illness prevention - Ans-Illness behavior involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system. Personal history, social situations, social norms, and past experiences can affect illness behavior. 9. A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model? A) Perceived threat of the disease B) Likelihood of taking preventive health action C) Analysis of perceived benefits of preventive action D) Perceived susceptibility to the disease. - Ans-The health belief model addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how they will comply with health care therapies. In the perceived susceptibility to the disease phase, the patient recognizes the familial link to the disease. 10. A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take? A) Care for the boy as she would any other patient B) Ask the manager to talk with the father and keep him out of the unit C) Have another nurse care for the boy because maybe that nurse will do better with the father D) Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community - Ans-The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. If nurses are not aware of their own and other cultural patterns of behavior and language, they may not be able to recognize and understand a patient's behavior and beliefs and may have difficulty interacting with the patient. 11. A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image? A) "I just don't have any energy to get out of bed in the morning." B) "I've been attending church regularly with my wife since I got out of the hospital." C) "My wife has taken over paying the bills since I've been in the hospital." D) "I don't go out very much because everyone stares at me." - Ans-The amputation resulted in a change in physical appearance that caused a change in body image. Reactions of patients and families to changes in body image depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available. When a change in body image such as results from a leg amputation occurs, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. The patient's statement indicates he is in the stage of withdrawal. 12. The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change? A) Precontemplation B) Contemplation C) Preparation D) Action - Ans-The patient is in the action stage of behavioral change. In this stage the patient is actively engaged in strategies to change behavior. This stage may last up to 6 months. 13. The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness? A) "I don't have time to exercise because I have to work after school every night." B) "I'm worried about becoming overweight and getting diabetes because my father has diabetes." C) "The statistics of how many teenagers are overweight is scary." D) "I've decided to start a walking club at school for interested students." - Ans-The statement indicates that the patient is concerned about developing diabetes and believes that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the patient may perceive the personal risk for diabetes. 14. The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.) A) Sedentary lifestyle B) Father died from CAD at age 50 C) History of hypertension D) Eats diet high in sodium E) Elevated cholesterol level F) Age is 44 years - Ans-Genetic and physiological risk factors include those related to heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of coronary artery disease is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease. 15. Which activity represents secondary prevention? A) A home health care nurse visits a patient's home to change a wound dressing. B) A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked. C) The school health nurse provides a program to the first-year students on healthy eating. D) The patient attends cardiac rehabilitation sessions weekly. - Ans-Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. 16. A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: A) She does not touch the patients either. B) Touch is a type of verbal communication. C) There is never a problem with using touch. D) Touch forms a connection between nurse and patient. - Ans-D.Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact. 17. Of the five caring processes described by Swanson, which describes "knowing the patient"? A) Anticipating the patient's cultural preferences B) Determining the patient's physician preference C) Establishing an understanding of a specific patient D) Gathering task-oriented information during assessment - Ans-C.Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help him or her. Strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise. 18. A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?" A) Sharing feelings about the importance of having regular woman's health examinations B) Gaining an understanding of what a woman's health examination means to the patient C) Recognizing that the patient is modest; obtaining gendercongruent caregiver D) Explaining the risk factors for cervical cancer - Ans-B. You should strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care. 19. Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes? A) Knowing B) Enabling C) Doing for D) Being with - Ans-B. The caring behavior of enabling facilitates the other's passage through life transitions (e.g., birth, death) and unfamiliar events. When a nurse practices enabling, the patient and nurse work together to identify alternatives and resources. 20. A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: A) "Spiritual care should be left to a professional." B) "You are correct, religion is a personal decision." C) "Nurses should not force their religious beliefs on patients." D) "Spiritual, mind, and body connections can affect health." - Ans-D. Spirituality offers a sense of connectedness, intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power). In a caring relationship the patient and nurse come to know one another so both move toward a healing relationship. 21. Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? A) Increasing the working hours of the staff B) Increasing salary benefits of the staff C) Creating a setting that allows flexibility and autonomy for staff D) Encouraging increased input concerning nursing functions from physicians - Ans-C.These factors all affect nursing satisfaction. When nurses' job satisfaction is high, they have a greater connectedness with their patients and believe that caring practices are part of the nursing culture. 22. When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: A) Instilling hope and faith. B) Forming a human-altruistic value system. C) Cultural caring. D) Being with. - Ans-A. Instilling hope and faith helps to increase an individual's capacity to get through an event or transition and face the future with meaning. 23. An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: A) Making health care decisions for patients. B) Having family members provide a patient's total personal hygiene. C) Injecting the nurse's perceptions about the level of care provided. D) Asking permission before performing a procedure on a patient. - Ans-D. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members. 24. A nurse demonstrates caring by helping family members: A) Become active participants in care. B) Provide activities of daily living (ADLs). C) Remove themselves from personal care. D) Make health care decisions for the patient. - Ans-A. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members. 25. Listening is not only "taking in" what a patient says; it also includes: A) Incorporating the views of the physician. B) Correcting any errors in the patient's understanding. C) Injecting the nurse's personal views and statements. D) Interpreting and understanding what the patient means. - Ans-D. Listening is powerful. It conveys the nurse's full attention and interest. A true caring presence involves listening. Listen to what is important to another person and the meaning of a situation to that person. 26. A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? A) The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. B) The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. C) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. D) The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively. - Ans-C. Attentive listening lets the nurse hear the patient's story and then correctly summarize it. It does not occur when the nurse is distracted by equipment or other personnel. The importance of listening is not to distract the patient or solve the problem, but rather to hear what the patient has to say and understand what the situation means to him. 27. Presence involves a person-to-person encounter that: A) Enables patients to care for self. B) Provides personal care to a patient. C) Conveys a closeness and a sense of caring. D) Describes being in close contact with a patient. - Ans-C. Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves "being there" and "being with." "Being there" is not only a physical presence but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances. 28. A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? A) Caring touch B) Protective touch C) Task-oriented touch D) Interpersonal touch - Ans-C. Nurses use task-orientated touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern. 29. A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? A) Caring touch B) Protective touch C) Task-oriented touch D) Interpersonal touch - Ans-A. Caring touch is a form of nonverbal communication. You express this in the way you hold a patient's hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally. 30. Match the following caring behaviors with their definitions. A. Sustaining faith in one's capacity to get through a situation B. Striving to understand an event's meaning for another person C. Being emotionally there for another person D. Providing for another as he or she would do for themselves. 31. Knowing 32. Being with 33. Doing for 34. Maintaining belief - Ans-Striving to understand an event's meaning for another person:Knowing, Being emotionally there for another person:Being with, Providing for another as he or she would do for themselves.:Doing for, Sustaining faith in one's capacity to get through a situation:Maintaining belief 35. The nurse's first action after discovering an electrical fire in a patient's room is to: A) Activate the fire alarm. B) Confine the fire by closing all doors and windows. C) Remove all patients in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher. - Ans-C. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger 36. A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A) Give the child milk. B) Give the child syrup of ipecac. C) Call the poison control center. D) Take the child to the emergency department. - Ans-C. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning 37. The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A) Activity intolerance B) Impaired bed mobility C) Acute pain D) Risk for falls - Ans-D. For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls 38. A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A) Home accidents B) Physiological changes of aging C) Poisoning and child abduction D) Automobile accidents, suicide, and substance abuse - Ans-D. Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. 39. The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A) Insert a urinary catheter. B) Leave a night light on in the bathroom. C) Ask the physician to order a restraint. D) Keep the bed in low position with upper and lower side rails up. E) Assign a staff member to stay with the patient. F) Provide scheduled toileting during the night shift. G) Keep the pathway from the bed to the bathroom clear. - Ans-B,F,G. Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and [Show More]

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