NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
Correct Answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.
Question 2 of 5
The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?
Correct Answer: D
Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.
Question 3 of 5
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
Correct Answer: A
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.
Question 4 of 5
The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
Correct Answer: A
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (
A). Left side-lying position (
B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (
C). Assisting the client in flexing the neck forward (
D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.
Question 5 of 5
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
Correct Answer: A
Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.