NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option
A) or increasing fluids (Option
D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option
B) is premature without understanding the client's baseline.
Therefore, assessing the client's medical record is the priority before proceeding with any interventions.
Question 2 of 5
An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which actions would be most effective to support family processes when the client returns home?
Correct Answer: B,D,E
Rationale: After the crisis time of a family member's suicide attempt, safety for the recovering individual is a priority. Families can provide support and encouragement in a caring home environment. Options 2, 4, and 5 offer helpful ways to enhance the family processes. Options 1 and 3 are clearly the least effective options because there is no information in the question that indicates that these actions are relative to the suicide attempt.
Question 3 of 5
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 4 of 5
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
Correct Answer: A
Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option
A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option
B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option
C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option
D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.
Question 5 of 5
A 79-year-old client with moderate dementia and limited mobility is being cared for at home by her son who lives with her. She has been receiving home health for care of a nonhealing diabetic foot ulcer. The home health nurse encourages the son to bring his mother to the ED for more aggressive treatment in an in-patient setting. The son responds that he cannot afford to pay for the medical bills and prefers to care for her at home. The nurse then notices a stage 2 decubitus ulcer on the client's sacrum. The son claims to have his sister come every day and assist with bathing and turning in the bed. Which type of violence is the son guilty of?
Correct Answer: A
Rationale: Physical neglect involves failing to provide adequate care, such as preventing pressure ulcers through proper turning, leading to conditions like the stage 2 decubitus ulcer.