NCLEX Questions Test Bank and Review 2019 / 2020 112th Edition
NCLEX Questions Test Bank and Review 2019 / 2020 112th Edition
1. A client is scheduled for an amniocentesis and tells the nurse, “I’m not sure I should have this test done.” Which response by the nurse is appropriate?
A. “Don’t worry. Everything will be fine.”
B. “The doctor has scheduled this test for a reason.”
C. “Why don’t you want to have this test done?”
D. “Tell me what concerns you have.”
Answer: D. “Tell me what concerns you have.”
Rationale: The nurse needs to gather more data and assist the client in exploring her feelings about the test. Options 1, 2, and 3 are blocks to communication and are nontherapeutic nursing responses.
Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Options 1, 2, and 3 are communication blocks. Option 4 is the only option that addresses the client’s feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 30-31.
2. A nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client would alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?
A. “I need to gain only 10 pounds so that my baby will be small like I am.”
B. “I really like to have a root beer float with vanilla ice cream in the afternoon.”
C. “I don’t like milk but I can drink it if it is in a shake mixed with chocolate.”
D. “I am not crazy about eating vegetables but I will do my best.”
Answer: A. “I need to gain only 10 pounds so that my baby will be small like I am.”
Rationale: Pregnant adolescents are at higher risk for complications than are other pregnant clients. Adolescents are often concerned about their body image. If weight is a major focus, the adolescent is more likely to restrict calories to avoid weight gain. Option 1 is the only response that suggests a possible concern. Options 2 and 3 indicate that the client will consume items that will help increase calcium intake. Option 4 expresses an attempt to consume required vegetables.
Test-Taking Strategy: Note the key words potential concern. Think about the developmental stage of the adolescent. Focus on the issue of body image that is so important for the adolescent. Then, by the process of elimination, you should easily be directed to option A. Review the developmental stage of the adolescent if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 318.
3. A nurse is providing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which of the following in the discussion?
A. Encouraging the need to avoid eating at local fast-food restaurants
B. Emphasizing the need to eliminate snack foods
C. Encouraging the adolescents to eat when hungry rather than three times a day
D. Describing the appropriate amount of weight gain required during the pregnancy
Answer: D. Describing the appropriate amount of weight gain required during the pregnancy
Rationale: The developmental stage of the adolescent needs to be addressed when the nurse is providing instructions regarding nutrition during pregnancy. The adolescent should not be told to eliminate favorite foods and places to eat. This may cause the adolescent to rebel. Eating only when hungry could lead to a deficit in nutrients. The adolescent is more likely to follow suggestions when the nurse explains why the weight gain is important.
Test-Taking Strategy: The client in this question is an adolescent. Consider the growth and development of an adolescent when answering this question. Eliminate option 3 first because it is not a physiologically sound suggestion. Next eliminate options 1 and 2 because these interventions will cause the adolescent to rebel. Review the needs of the pregnant adolescent related to nutrition if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 318.
4. A nurse is preparing a session regarding nutrition for a group of culturally diverse pregnant women. The nurse determines that the priority nursing intervention includes which of the following?
A. Describe the importance of avoiding eating at fast-food restaurants
B. Obtain the weight of each client
C. Determine the socioeconomic status of each client
D. Identify cultural food preferences
Answer: D. Identify cultural food preferences
Rationale: The priority nursing intervention is to identify the cultural food preferences of each client. This information is needed in order to adequately provide information regarding appropriate nutrition. The socioeconomic status may be an important component, particularly when the nurse is determining whether a client’s financial situation permits the purchase of appropriate food items. A baseline weight also may be important. Encouraging appropriate nutrition and the need to avoid fast-food restaurants is also important. However, an adequate nutritional regimen can be planned only if cultural food preferences are identified.
Test-Taking Strategy: Use the process of elimination to assist you in identifying the physiological needs that are directly related to the individual client. This will easily direct you to option D. Also note the relation of the word “culturally” in the question and “cultural” in the correct option. Review cultural considerations as they relate to nursing interventions if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 53.
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