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

Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options.

Physiological Adaptation

Advocacy for clients by nurses is the primary focus of the client’s right to autonomy and self-determination.

Confidentiality involves the maintenance of the privacy of the client and information regarding him or her.

Malpractice insurance is a type of insurance for professionals.Coordinated Care

Encouraging the client to identify his own strengths is the most effective strategy.Psychosocial Integrity

The 72-year-old client scheduled for heart transplant surgery may give informed consent for the surgery.

There are no age limitations with the exception of minors. Choices 1, 2, and 4 are incorrect. An individual with

advanced Alzheimer’s disease is incompetent to make decisions. Only an emancipated minor may give consent

(a 14-year-old child who lives alone, away from family, and is totally independent). Infants are unable to give

consent.Coordinated Care

The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The

focus of the PSDA is individual health care decision-making. A federal standard for advance directives does not

exist. Each state has jurisdiction regarding these policies and protocols.Coordinated Care

Assessment is the first step. Assessing what the client eats helps the nurse determine a plan for dietary

recommendations based on the ADA and AHA guidelines. Providing the client with a copy of the guidelines is

important but is not the first priority. Based on the client’s wish to reduce her chances of heart disease and

diabetes, a high-protein diet plan might not be appropriate. Providing information to the client related to risk

factors for heart disease and diabetes is important but is not the first step.Health Promotion and Management

The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time

limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not

known at the outset, and the client should know that this is an issue that is negotiated at a later date.Coordinated

Care

Restraints must be released every 2 hours, and the client must be assessed every 30 minutes while restrained.

Safety and Infection Control

The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and

transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.

Coordinated Care

Genital herpes can be transmitted by oral, genital, and anal sex. The other statements are myths.Safety and

Infection Control

This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses.

Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness.

Coordinated Care

Normal saline is 0.9% sodium chloride. This solution has the same osmolarity as blood. Its use does not

cause lysis of cells. Choices 2 and 3 are hypotonic solutions that can cause cell lysis. Choice 4 is an anticoagulant.

Pharmacological Therapies

Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful

event (rape) can strengthen the client’s coping. A nurse specialist in rape crisis intervention is educationally

prepared in counseling and crisis intervention specific to rape victims.Coordinated Care

The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use

of sunscreens and avoiding exposure.Safety and Infection Control

The posterior fontanel should close by the age of 2 months.Health Promotion and Maintenance