NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
Correct Answer: B
Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (
B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.
Question 2 of 5
The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. The nurse should recognize that which client objective is an unrealistic short-term goal?
Correct Answer: B
Rationale: Short-term goals include the beginning stages of dealing with the rape trauma. Clients will initially be expected to keep appointments, participate in care, start to explore feelings, and begin to heal the physical wounds that were inflicted at the time of the rape. The resolution of feelings of anxiety and fear is a long-term goal.
Question 3 of 5
After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
Correct Answer: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
Question 4 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 5 of 5
A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge should the nurse use to provide support to the client?
Correct Answer: D
Rationale: If the client tests positive for HIV with the ELISA test, the test is repeated because of the potential for a false-positive result (e.g., from a recent influenza or hepatitis B vaccine) or a false-negative result if drawn too early after infection. If the test is positive a second time, the Western blot (a more specific test) is done to confirm the finding. The client is not diagnosed as HIV positive unless the Western blot is positive. Some laboratories also run the Western blot a second time with a new specimen before making a final determination.