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Comprehensive NCLEX -RN Comprehensive Exam Q&A 2021

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. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 2. Adhering to the mandatory abuse-reporting laws 3. Notifying the caseworker of the family situation 4. Removing the client from any immediate danger 5. Obtaining treatment for the abusing family member2. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse’s immediate action? a. Incessant talking and sexual innuendoes b. Grandiose delusions and poor concentration c. Outlandish behaviors and inappropriate dress d. Nonstop physical activity and poor nutritional intake3. The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse’s best determination in planning care? a. The informed consent does not need to be obtained. b. The informed consent should be obtained from the family. c. The informed consent needs to be obtained from the client. d. The health care provider will provide the informed consent.4. A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse’s best response to the client’s question? a. “It will boost the cells in your pancreas if you have insufficient insulin.” b. “It will help promote insulin absorption when your glucose levels are high.” c. “It is for the times when your blood glucose is too low from too much insulin.” d. “It will help prevent lipoatrophy from the multiple insulin injections over the years.”5. The nurse is providing care to a Puerto Rican–American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client? 1. Restrict the number of family members visiting at one time. 2. Inform the family that emotional outbursts are to be avoided. 3. Make the necessary arrangements so that family members can visit. 4. Contact the primary health care provider to speak to the family regarding their behaviors.

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