NCLEX NCLEX-PN Exam Made Easy: Step-by-Step Preparation Guide

This statement reassures the client that there is a solution for relief of his anxiety. The other responses minimize the client’s feelings.Reduction of Risk Potential

Human chorionic gonadotropin is found in the urine during pregnancy and specifically indicates pregnancy. The other hormones do not.Reduction of Risk Potential

Pica represents the ingestion of nonfood substances that leads to a clinical iron deficiency and might actually be the first sign of a problem. Clients eat a wide range of nonfood items, including ice, clay, dirt, and paste.Physiological Adaptation

ADH level is increased in the client with nephrogenic diabetes insipidus.Reduction of Risk Potential

If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one—that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.

Psychosocial Integrity

Kegel exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence.Physiological Adaptation

The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice 1 is technically correct, but it doesn’t consider the immediate need for the couple to have some counseling. Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice 4 is still the most caring and correctanswer. Couples conceive within the first month of unprotected intercourse 20% of the time.Health Promotion and Maintenance

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

Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States.Physiological Adaptation

Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.Basic Care and Comfort

Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client’s chin and a curved basin against the chin. Gloves should be worn.Basic Care and Comfort

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

High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit.Physiological Adaptation

Apples are a source of high fiber, which decreases constipation. A constipated client needs to increase fluids and activity level. Milk is not a high-fiber food.Reduction of Risk Potential

The client needs to learn how to communicate directly with his wife about her behavior. The nurse’s assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the clientand toward his wife, who isn’t present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he’ll waste precious time convincing the nurse that he or she should do his work.Psychosocial Integrity