NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet Questions
Question 1 of 5
Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
Correct Answer: B
Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.
Question 2 of 5
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
Correct Answer: B
Rationale: Option B is the correct procedure for assisting a client from the bed to a chair. By positioning the nurse's feet apart and aligning the knees with the client's knees, the nurse maintains a stable base of support while pivoting the client into the chair. This technique minimizes the risk of injury to both the nurse and the client. Placing the chair at a 45-degree angle to the bed, with the back of the chair toward the head of the bed, provides a clear path for the client to move. Option C is incorrect because lifting a client under the axillae can potentially cause nerve damage and strain. Option D is also incorrect as it involves an unsafe method of moving the client and can lead to injuries or accidents.
Question 3 of 5
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
Correct Answer: C
Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.
Question 4 of 5
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
Correct Answer: A
Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.
Question 5 of 5
When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?
Correct Answer: A
Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination. Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.