NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is to have arterial blood gases drawn. While the nurse is performing Allen's test, the client states to the nurse, 'What are you doing? No one else has done that!' Which response the nurse makes to the client is most therapeutic?
Correct Answer: D
Rationale: Allen's test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response provides information to the client. Option 1 is defensive and nontherapeutic in that it offers false reassurance. Option 2 identifies client advocacy, but it is overly controlling and aggressive, and undermines treatment. Option 3 is aggressive, controlling, and nontherapeutic in its disapproving stance.
Question 2 of 5
The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?
Correct Answer: C
Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration.
Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.
Question 3 of 5
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 (SA
D) 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 4 of 5
A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.
Question 5 of 5
Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
Correct Answer: D
Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery.
Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified.
Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase.
Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.