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  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 311

A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

Correct Answer: D
Explanation/Reference:
Explanation:
(A) To the client, suicide may be a reasonable action and the only one he can cope with at this time. (B) This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. (C) The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. (D) This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
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Question 312

In teaching the client about proper umbilical cord care, the nurse recommends that:

Correct Answer: C
(A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
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Question 313

A schizophrenic client has made sexual overtures toward her physician on numerous
occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

Correct Answer: B
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
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Question 314

A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

Correct Answer: B
Explanation
(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24-48 hours.
The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The client's mouth may become dry, but good oral care should take care of the dryness.
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Question 315

A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:

Correct Answer: A
Explanation/Reference:
Explanation:
(A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexia. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin.
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