Free NCLEX-RN Exam Braindumps (page: 87)

Page 87 of 431

The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

  1. Ordering a full liquid diet for her
  2. Ordering five small meals for her
  3. Ordering a mechanical soft diet for her
  4. Ordering a puréed diet for her

Answer(s): C

Explanation:

(A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first.



The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

  1. Ordering a full liquid diet for her
  2. Ordering five small meals for her
  3. Ordering a mechanical soft diet for her
  4. Ordering a puréed diet for her

Answer(s): C

Explanation:

(A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first.



A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

  1. Placing her in seclusion until the behavior is under control
  2. Walking up to the client and touching her on the arm to get her attention
  3. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
  4. Confronting the client, letting her know the consequences for getting angry and disrupting the unit

Answer(s): C

Explanation:

(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.



A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

  1. Placing her in seclusion until the behavior is under control
  2. Walking up to the client and touching her on the arm to get her attention
  3. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
  4. Confronting the client, letting her know the consequences for getting angry and disrupting the unit

Answer(s): C

Explanation:

(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.



Page 87 of 431



Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:

Naveen Ahlam commented on November 29, 2024
Great stuff
Anonymous
upvote

Isadora Guimarães commented on November 10, 2024
Very good to study
UNITED STATES
upvote

Marydee commented on April 02, 2020
Just purchased, will see if it is the real deal. Will give a further update later!
Anonymous
upvote