NCLEX PN Exam Test Bank and Study Guide With NGN Real Exam Questions and Verified Answers with Rationales For Guaranteed

Thenurseismonitoring aclient whoisin activelaborwithacervicaldilationof6 sm. Whichfindingrequiresinterventionbythe nurse?

A)Contraction duration of 95 seconds

B)Contraction frequency of every 3 minutes C)Contraction intensity of 45 mm Hg D)Uterine resting tone of 10 mm Hg

A

Uterine contractions in the first stage of labor:

DURATION- 45-80 seconds, should not exceed 90 seconds (reduction of blood flow to the placenta)

FREQUENCY: 2-5 contractions every 10 minutes, should not occur more frequently than every 2 minutes (fetal distress from uteroplacental insufficiency) INTENSITY: Strength at peak time (25-50 mmHg), should not exceed 80 mm Hg (sign of hypertonicity of the uterus)

RESTING TONE: Tension in uterine muscle between contractions, allows fetal oxygenation between contractions, average 10 mm Hg, should not exceed 20 mm Hg

The nurse is caring for a client who has been hospitalized for major depressive disorder. When the nurse reminds the client that breakfast will be served in the dining room in 20 minutes, the client says, "I'm not hungry and don't feel like doing anything." Which is the best response by the nurse?

A)"I will help you get ready, then we can walk to the dining room together."

B)"I will have breakfast brought to your room. I know you don't have much energy right now."

C)"It is okay. You can join us when you are ready. Take your time."

D)You will feel better when you get up and get dressed. You need to eat something."

A

reduced appetite and low energy level are common in major depressive disorder. Hard to get out of bed and perform ADLs. Client needs direction and structure with their ADLs also assistance.

The nurse should assist the client with completing ADLs and with initiating social interaction with others.

A client with borderline personality disorder says to the nurse, "Your the only one I trust around here. the others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority nursing action?

A)Assign different staff members to care for the client each day

B)Assign the client's stated preferred nurse to care for the client

C)Reassurethe client thatallstaff members arecompetent intheirjobs

D)Reinforce unit guidelines and appropriate boundaries with the client

D

BPD is characterized by intense impulsivity and emotional dysregulation combined with unstable relationships and self image. They fear abandonment and rejection. Use manipulative behavior for control (flattery or distancing)

Splitting is a defense mechanism where BPD patients hold opposing thoughts and perceive people or events as "all good" or "all bad." Staff should prevent this by calmly reinforcing unit guidelines and appropriate boundaries.

The nurse is caring for a 3 year old child. The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My child has never been aggressive before but he has always been particular about food." The client was born at full term without complication and has no significant medical history. The child started babbling at age 6 months,and the parent reports that the first words were spoken around age 12 months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color. The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vital signs are normal, and the client's tracking adequately on growth curves. During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow the parent's gaze when the parent points to toys in the office. The child begins screaming and rocking Quiet and "obsessed" with stacking blocks and organizing toys by color. Now says two-word phrases. Client does not follow the parent's gaze when pointing to toys in the office. Child screams and rocks back and forth when the HCP comes near.

Autism spectrum disorder is a neurodevelopmental condition characterized by impaired social skills and interpersonal communication, Manifestations include restricted activities and interest, delayed speech, poor eye contact, and repetitive patterns and behaviors.

For each finding below, click to specify if the finding is consistent with the disease process of autism spectrum disorder, OCD, or separation anxiety. Each may support more than one disease process.

Ritualized pattern of behavior Disinterest in social interaction Lack of spontaneous eye contact restricted, fixed thoughts or interests.

OCD: Ritualized pattern of behavior and restricted, fixed thoughts or interests. SEPARATION ANXIETY: Disinterest in social interaction

The client is diagnosed with autism (ASD). The nurse recognizes that clients with

ASD are at risk for which of the following complications? SATA

A) Impaired interpersonal relationships

B) Learning difficulties

C) Malnutrition

D) Self-harm behavior

E) Sleep disturbances A, B, C, D, E

ASD begins in the developmental period, and symptoms tend to persist through life.More prone to psychiatric, medical, psychosocial impairments (impaired interpersonal relationships, learning difficulties, malnutrition, self-harm, and sleep disturbances).

For each potential intervention, click to specify if the intervention is anticipated or not for the cafre of the client.

Encourage the client to play with others in the playroom Follow a structured routine and schedule for providing care

Consistently assign the same nursing staff to the client when possible Assign the client to a shared room with another child with ASD

Use direct eye contact and therapeutic touch when talking to the client

ANTICIPATED:Followastructuredroutineandscheduleforprovidingcareand consistentlyassignthe same nursingstaff tothe clientwhenpossible.

NOT ANTICIPATED: Encourage the client to play with others in the playroom, assign the client to a shared room with another child with ASD, and use direct eye contact and therapeutic touch when talking to the client

The client is newly prescribed aripiprazole for ASD. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate?

A)Abruptly stopping the medication can cause withdrawal symptoms."

B)"Aripiprazole will cure your child's ASD."