NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Question 1 of 9
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
Question 2 of 9
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
Correct Answer: B
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.
Question 3 of 9
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.
Question 4 of 9
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
Question 5 of 9
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
Correct Answer: D
Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.
Question 6 of 9
A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?
Correct Answer: A
Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.
Question 7 of 9
Which of the following mental health situations is considered a psychiatric emergency?
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
Question 8 of 9
When administering medications through a nasogastric tube connected to low intermittent suction, which action should the nurse do first?
Correct Answer: D
Rationale: When administering medications through a nasogastric tube connected to low intermittent suction, the nurse should first turn off the intermittent suction device. This step is crucial to prevent the medications from being immediately suctioned out before they can be absorbed. Clamping the nasogastric tube is not the initial action because it may cause pressure buildup and lead to complications. Confirming the placement of the tube is important but should not be the first step in this scenario. Using a syringe to instill the medications comes after ensuring the suction is turned off to enable proper administration and absorption of the medications.
Question 9 of 9
The client with cholecystitis is being instructed about dietary choices. Which meal best meets the dietary needs of this client?
Correct Answer: B
Rationale: Clients with cholecystitis, which is inflammation of the gallbladder, should follow a low-fat diet to reduce symptoms. Broiled fish, green beans, and an apple (Option B) is the most suitable choice as it is low in fat. Steak, baked beans, and a salad (Option A) provide a high amount of fat and protein, which may exacerbate symptoms of cholecystitis. Pork chops, macaroni and cheese, and grapes (Option C) and avocado salad, milk, and angel food cake (Option D) contain high-fat foods that are not recommended for individuals with cholecystitis. Therefore, Option B is the most appropriate choice for a client with cholecystitis.