NCLEX-RN
NCLEX Patient Needs Psychosocial Integrity Therapeutic Communications Questions
Extract:
Question 1 of 5
A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks' gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the primary health care provider will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, 'No, no, you can't go, my little man.' The nurse should recognize the client's behavior as an indication of which psychosocial reaction?
Correct Answer: C
Rationale: Grief occurs when a client has knowledge of an impending loss, such as when signs of fetal distress accelerate. The first stages of grieving may be characterized by shock; emotional numbness; disbelief; and strong emotions such as tears, screaming, or anger. The remaining options are not focused on the mother's expressed concerns.
Question 2 of 5
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
Question 3 of 5
The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, 'You won't have to worry about me much longer.' Which meaning should the nurse interpret from this statement?
Correct Answer: A
Rationale: A client who is at risk for suicide who says, 'You won't have to worry about me much longer,' is making an expression of a suicidal intent. Although depression, self-mutilation, and hopelessness may relate to violence to oneself, the statement that he or she will not be around is a direct comment about the act of suicide.
Question 4 of 5
A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client?
Correct Answer: D
Rationale: The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. This information supports that the remaining options are not accurate.
Question 5 of 5
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.