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51. A cooling blanket is prescribed for a child with a fever. A nurse caring for the child has never used this type of equipment, and the charge nurse provides instructions and observes the nurse using the cooling blanket. The charge nurse intervenes if the nurse:
a) keeps the child uncovered to assist in reducing the fever
b) places the cooling blanket on the bed and covers the blanket with a sheet
c) keeps the child dry while on the cooling blanket to reduce the risk of frostbite
d) checks the skin condition of the child before, during, and after the use of the cooling blanket
52. A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which situation, if identified by the student, would indicate the need for further study of the levels of prevention?
a) teaching s stroke client how to use a walker
b) screening for hypertension in a community group
c) screening for hyperlipidemia in a community group
d) encouraging a woman who is more than 40 years old to obtain periodic mammograms
53. A charge nurse is supervising a new registered nurse (RN) who is providing care to a client with end-stage heart failure. The client is withdrawn and reluctant to talk, and she shows little interest in participating in hygienic care or activities. Which statement, if made by the new RN to the client, indicates that the new RN requires further teaching regarding the use of therapeutic communication techniques?
a) what are your feelings right now?
b) why don't you feel like getting up for your bath?
c) these dreams you mentioned, what are they like?
d) many clients with end-stage heart failure fear death
54. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse would intervene if which of the following is performed by the nursing assistant during communication with the client?
a) the nursing assistant is speaking in a normal tone
b) the nursing assistant is speaking clearly to the client
c) the nursing assistant is facing the client when speaking
d) the nursing assistant is speaking directly into the impaired ear
55. A charge nurse reviews the plan of care formulated by a new nursing graduate for a child returning from the operating room after a tonsillectomy. The charge nurse assists the new nursing graduate with changing the plan if which incorrect intervention is documented?
a) suction whenever necessary
b) offer clear, cool liquids when awake
c) monitor for bleeding from the surgical site
d) eliminate milk or milk products from the diet
Leadership NCLEX Questions
Answers and Rationale
- While on a cooling blanket, the child should be covered lightly to maintain privacy and reduce shivering. Options B, C, and D are important interventions to prevent shivering, frostbite, and skin breakdown.
- Secondary prevention focuses on the early diagnosis and prompt treatment of disease. Tertiary prevention is represented by rehabilitation services. Options B, C, and D identify screening procedures. Option A identifies a rehabilitative service.
- When the nurse asks a "why" question of the client, the nurse is requesting an explanation for feelings and behaviors when the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option A, the nurse is encouraging the verbalization of emotions or feelings, which is a therapeutic communication technique. In option C, the nurse is using the therapeutic communication technique of exploring, which involves asking the client to describe something in more detail or to discuss it more fully. In option D, the nurse is using the therapeutic communication technique of giving information. Identifying the common fear of death among clients with end-stage heart failure may encourage the client to voice concerns.
- When communicating with a hearing-impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client, and he or she should speak clearly. If the client does not seem to understand what is being said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse needs to avoid talking directly into the impaired ear.
- After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding. Option C is an important intervention after any type of surgery.
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