Free NCLEX-RN Exam Braindumps (page: 122)

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A client is diagnosed with organic brain disorder. The nursing care should include:

  1. Organized, safe environment
  2. Long, extended family visits
  3. Detailed Explanation of procedures
  4. Challenging educational programs

Answer(s): A

Explanation:

(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple Explanation are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.



A client is diagnosed with organic brain disorder. The nursing care should include:

  1. Organized, safe environment
  2. Long, extended family visits
  3. Detailed Explanation of procedures
  4. Challenging educational programs

Answer(s): A

Explanation:

(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple Explanation are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.



A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

  1. Fourth stage of labor
  2. Third stage of labor
  3. Transition stage of labor
  4. Second stage of labor

Answer(s): C

Explanation:

(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.



A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

  1. Fourth stage of labor
  2. Third stage of labor
  3. Transition stage of labor
  4. Second stage of labor

Answer(s): C

Explanation:

(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.






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