NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
A client who received an implanted port for intermittent chemotherapy says, 'I'm not sure if I can handle having a tube coming out of me. What will my friends think?' Which action should the nurse implement first?
Correct Answer: C
Rationale: An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when an intravenous line is connected, and the port is accessed for therapy. The remaining options do not correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring about the client's friends is a reasonable response, but it can also provide false hope that the friends will be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be beneficial because the client will not be using them; in addition, this can heighten client anxiety and concerns.
Question 2 of 5
The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
Correct Answer: D
Rationale: This response addresses the family's question while opening a discussion about care goals, which is supportive and appropriate.
Question 3 of 5
The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement?
Correct Answer: A
Rationale: Keeping the room organized and clean minimizes sensory overload and confusion, promoting a calming environment for a client with delirium. High noise, dim lights, or restraints can worsen agitation and are not appropriate unless safety is imminently threatened.
Question 4 of 5
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, 'The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?' Which is the most appropriate therapeutic response the nurse should make to the client?
Correct Answer: B
Rationale: Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no problems are associated with this procedure; this is closed-ended and is incorrect. Although option 4 contains accurate information, the word immediately can increase the client's anxiety.
Question 5 of 5
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
Correct Answer: B,C,E
Rationale: Grief is influenced by age, gender, and culture (
B), nurses must process their own feelings about death (
C), and helping families cope with loneliness/depression (E) is appropriate. Grief is not inherently detrimental (
A), and discouraging expression (
D) is counterproductive.