NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
Correct Answer: A
Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.
Question 2 of 5
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
Correct Answer: D
Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option
A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.
Question 3 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.
Question 4 of 5
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
Correct Answer: D
Rationale:
To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (
Choice
A) may lead to unreliable information, and a drug reference book (
Choice
B) may not address individualized questions. While the written instructions may contain information (
Choice
C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.
Question 5 of 5
The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client?
Correct Answer: A
Rationale: Acknowledging the client's feelings without inserting your own values or judgments is a method of therapeutic communication. Therapeutic communication techniques assist with the flow of communication, and they always focus on the client. Option 1 is an open-ended statement that allows the client to verbalize, which gives the nurse a direction or clarification of the client's true feelings. The remaining options do not encourage verbalization by the client.