NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
Question 2 of 5
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building.
Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
Question 3 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 4 of 5
The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should the nurse provide to ensure the optimal benefits from the drug?
Correct Answer: B
Rationale:
To ensure optimal benefits from a metered-dose inhaler, the client should be instructed to compress the inhaler while slowly breathing in through the mouth. This technique facilitates the medication to reach deep into the lungs, allowing for an optimal bronchodilation effect. Option B is correct as it promotes the proper coordination of inhaler compression and inhalation, ensuring effective drug delivery. Options A, C, and D are incorrect as they do not support deep lung penetration of the medication, which is essential for its effectiveness in treating respiratory conditions.
Question 5 of 5
A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?
Correct Answer: A
Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.