NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which intervention is most appropriate for the nurse to implement at this time?
Correct Answer: A
Rationale: It is normal for clients who experience thyroid storm (hyperthyroidism) to continue to be anxious and emotionally labile at the time of discharge. The best intervention is to help the client cope with these changes in behavior and to anticipate potential stressors so that symptoms will not be as severe. Options 2 and 3 block communication by either avoiding the issue or providing false reassurance. The confrontation described in option 4 will only heighten his anxiety.
Question 2 of 5
Which communication technique is a part of therapeutic communication?
Correct Answer: D
Rationale: The correct answer is providing relevant information to the client. In therapeutic communication, it is essential to provide clients with all pertinent information to help them understand their health status and what to expect. This empowers clients and promotes trust in the nurse-client relationship. Asking for explanations, showing sympathy, and asking personal questions are examples of nontherapeutic communication techniques. Asking personal questions can intrude on the client's privacy and may not be relevant to their care. Showing sympathy, while well-intentioned, may come across as pity rather than true empathy. Asking for explanations can sometimes put clients on the defensive rather than fostering a collaborative dialogue.
Question 3 of 5
The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
Correct Answer: D
Rationale:
To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
Question 4 of 5
A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which intervention is most appropriate for the nurse to implement at this time?
Correct Answer: A
Rationale: It is normal for clients who experience thyroid storm (hyperthyroidism) to continue to be anxious and emotionally labile at the time of discharge. The best intervention is to help the client cope with these changes in behavior and to anticipate potential stressors so that symptoms will not be as severe. Options 2 and 3 block communication by either avoiding the issue or providing false reassurance. The confrontation described in option 4 will only heighten his anxiety.
Question 5 of 5
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.