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NCLEX-PN Exam Questions - Part 77
1. All of the following clients are in need of an emergency assessment except:
A) a bleeding client who has an injury from falling debris.
B) an unresponsive client.
C) a client with an old injury.
D) a pregnant woman with imminent delivery.
2. All of the following are causes of vaginal bleeding in late pregnancy except:
A) placenta previa.
B) eclampsia.
C) abruptio placentae.
D) uterine rupture.
3. Padding on a restraint helps:
A) with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints.
B) the client feel more secure.
C) to keep infection and wounds down.
D) to keep restraints in place.
4. What does client and family communication and education concerning restraints do?
A) confuses both groups more
B) helps with coping and stress levels
C) encourages cooperation with the client and family
D) puts the responsibility on the client and family, not the nurse
5. Which of the following statements describes the purpose of client restraint?
A) Restraints are a nursing measure used to maintain client control.
B) Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C) Restraints are a therapeutic measure designed to positively reinforce client behavior.
D) Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
A) a bleeding client who has an injury from falling debris.
B) an unresponsive client.
C) a client with an old injury.
D) a pregnant woman with imminent delivery.
2. All of the following are causes of vaginal bleeding in late pregnancy except:
A) placenta previa.
B) eclampsia.
C) abruptio placentae.
D) uterine rupture.
3. Padding on a restraint helps:
A) with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints.
B) the client feel more secure.
C) to keep infection and wounds down.
D) to keep restraints in place.
4. What does client and family communication and education concerning restraints do?
A) confuses both groups more
B) helps with coping and stress levels
C) encourages cooperation with the client and family
D) puts the responsibility on the client and family, not the nurse
5. Which of the following statements describes the purpose of client restraint?
A) Restraints are a nursing measure used to maintain client control.
B) Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C) Restraints are a therapeutic measure designed to positively reinforce client behavior.
D) Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
1. Right Answer: C
Explanation: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition. Safety and InfectionControl
2. Right Answer: B
Explanation: Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally. Safety and Infection Control
3. Right Answer: A
Explanation: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia. Safetyand Infection Control
4. Right Answer: C
Explanation: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints.Well-meaning family members might release restraints if their purpose is not clear.Safety and Infection Control
5. Right Answer: B
Explanation: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physicians order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider. Safety and Infection Control
Explanation: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition. Safety and InfectionControl
2. Right Answer: B
Explanation: Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally. Safety and Infection Control
3. Right Answer: A
Explanation: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia. Safetyand Infection Control
4. Right Answer: C
Explanation: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints.Well-meaning family members might release restraints if their purpose is not clear.Safety and Infection Control
5. Right Answer: B
Explanation: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physicians order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider. Safety and Infection Control
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